Australian Health Practitioner Regulation Agency - Former Bacchus Marsh clinical care director disqualified
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Former Bacchus Marsh clinical care director disqualified

31 May 2022

A tribunal has found the former Director of Clinical and Quality Support Services at Bacchus Marsh Hospital failed in key aspects of her former role during the cluster of stillbirths and newborn deaths at the hospital.

Trigger warning: Some readers may find this article distressing. If you are experiencing distress and are a registered medical practitioner or medical student, please visit the drs4drs website for support in your state or territory. Any readers can contact Lifeline on 13 11 14 for help.

Key points
  • A tribunal has reprimanded and disqualified for two years Elizabeth Wilson, former Director of Clinical and Quality Support Services at Bacchus Marsh Hospital (operated by Djerriwarrah Health Services (DjHS)). She has been unregistered since 2016.
  • Five allegations of professional misconduct and unprofessional conduct were proven relating to her time working at the hospital during the cluster of stillbirths and newborn deaths.
  • As Ms Wilson was a registered physiotherapist at the time, the Physiotherapy Board of Australia (the Board) was seeking a 10-year disqualification period.

The Victorian and Civil and Administrative Tribunal (the tribunal) found five allegations proven against Elizabeth Wilson, a formerly registered physiotherapist, which arise from her performance in the role between 2009 and 2015.  

The allegations include: 

  • failure to ensure the effective investigation, management and analysis of incidents reported by staff and, in particular, failure to ensure that all perinatal deaths were subject to appropriate clinical review
  • failure to ensure DjHS had an organisational system that required clinical areas to identify their clinical risks and ensure there was relevant training and education of staff so that practice was consistent with the relevant standard (this was a shared responsibility)
  • failure to ensure the service had clear booking and transfer criteria suitable to its capacity, and failure to ensure booking and transfer controls were utilised (this was a shared responsibility)
  •  failure to ensure that health service incident management policies reflected the department policy and clinical governance policy framework, and
  • failure to undertake formal reflective practice activity or training to identify gaps in skills, knowledge and ability.

While the Board and Ms Wilson agreed that the first three proven allegations amounted to professional misconduct, the tribunal decided that only the first allegation amounted to professional misconduct with the remaining allegations amounting to the less serious category of unprofessional conduct.  

Despite the Board and Ms Wilson agreeing to a 10 year disqualification period, the tribunal disagreed and substituted its own, reduced decision. Ms Wilson has not been registered since 2016 and is retired.

Board Chair, Kim Gibson, said: ‘This result, while not as long as we feel was warranted, hopefully supports the healing of those families who tragically lost babies. Clinical governance responsibilities were clearly not meeting the standards we expect of practitioners and what the public expects when receiving care. Health practitioners, particularly those in leadership roles, have professional responsibility at all levels to ensure the delivery of safe and quality care. This includes overseeing the safe delivery of care by their employees.’

‘While this outcome may bring little comfort to those families affected by the tragic deaths of babies at Bacchus Marsh, we hope that it does help ensure that babies and families will be safer in the future,’ Ahpra CEO, Martin Fletcher, said.

The full decision is published on the Austlii website.


In February 2016, Ahpra and the National Boards launched investigations in relation to 101 matters about the care provided by individual practitioners at the Bacchus Marsh Hospital during the period of October 2011 to February 2013. This followed a cluster of potentially preventable stillbirths and neonatal deaths at the Bacchus Marsh Hospital (operated by Djerriwarrh Health Service).

Forty three registered health practitioners were the subject of concerns in the 101 matters reported (some practitioners were the subject of multiple notifications). All investigations have finalised, with some practitioners awaiting hearing in the Victorian Civil and Administrative Tribunal.

For the 43 registered health practitioners reported, almost half (21 practitioners) had matters which were able to be closed without the need for regulatory action. This includes practitioners who surrendered their registration or who had already undertaken steps towards remediation, which a National Board considers sufficient to manage any ongoing risk to the public. For example, when a practitioner has completed education or training that addresses any gaps identified in their skills or knowledge.

For those practitioners where further action was taken:

  • six practitioners were cautioned
  • six practitioners had conditions imposed on their registration (including those who were cautioned and had conditions imposed), and
  • ten practitioners were referred to a panel hearing or the Victorian Civil and Administrative Tribunal.

Further information about the possible outcomes of a notification can be found on the Ahpra website.

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Page reviewed 31/05/2022