For the past few months, the Australian public has been following one of the worst cases of medical negligence and malpractice ever to occur in Victoria: the tragic deaths of babies at the Bacchus Marsh and Melton Regional Hospital. The revelation came after an independent review found that, following a significant increase in baby deaths at the Bacchus Marsh hospital between 2013 and 2014 – later linked to systemic failures – many of them could have been avoided.
“As patients, we are entitled to be active participants in our health care and so we should be wary of doctors who are unable or unwilling to explain a diagnosis, the pros and cons of proposed treatment, the risks and potential complications of surgery, medication or other treatment.”
The Department of Health’s Consultative Council of Paediatric Mortality and Morbidity (CCOPMM) noticed the unusually high number of perinatal deaths between 2013 and 2014, prompting a wider review by Professor Euan Wallace, a well-respected obstetrician. It found that seven of these deaths may have been avoidable. The review attributed these outcomes to poor prenatal care and the overall conduct of the hospital’s obstetric services.
The government has since asked Professor Wallace, from Monash Health, to look further back at deaths at the hospital dating back to 2001, when recording of perinatal deaths began. His investigation uncovered seven more baby deaths, bringing the total number of deaths at the maternity unit to 18. A number of injuries, resulting in debilitating conditions such as cerebral palsy, have also been found.
“We’ve never had anything like this in Victoria; one hospital, one department, similar kinds of high-risk patients being mistreated and a misinterpreting of cardiotocography monitoring traces that’s unprecedented in Victoria,” says Dimitra Dubrow, a medical law expert and partner at Maurice Blackburn, who has been representing many of the affected families.
The case has become a major source of concern given that AHPRA, the regulatory and disciplinary body tasked with dealing with notifications about the health, performance and conduct of health practitioners, delayed making a finding about Dr Surinder Parhar, a senior obstetrician and head of obstetrics at Bacchus Marsh Hospital for more than 30 years (he retired in the middle of 2015, just before the news broke), for 28 months. Speaking to Neos Kosmos, Dimitra Dubrow offered valuable insight to the case, while expressing relief, as one by one, grieving families start to receive compensation.
After months of investigation and work on so many levels, the Bacchus Marsh and Melton Regional Hospital failures seem to be nearing some closure. What is your take on this issue?
The events that occurred at Bacchus Marsh are unprecedented in Victoria. We have not had so many deaths concentrated in time, involving one area of medical speciality and one hospital. The magnitude of the tragedy prompted Health Minister Jill Hennessy to refer to what happened as “… a series of catastrophic failures …”.
The most important and persisting question remains: how was this allowed to happen? Was it a lack of awareness that the obstetric care was not as it should be? That the burden of increasing numbers of deliveries was taking its toll? That high-risk obstetric patients were being cared for when the hospital was not equipped and not supposed to manage such patients? That the funding was simply inadequate for the staffing and patient needs?
Although these events have never happened before, some of the contributing factors are not unique to these events. Time and time again we see injury and death resulting from systemic issues including poor communication, failure to comply with policies and guidelines, inadequate resourcing and equipment, failure to recognise and act on concerning signs, and deteriorating conditions and competency issues are common as well. These events highlight the need for us to get the training and resourcing right in our hospitals and to be across changing demographics and population growth corridors.
We also need a timely and robust system of reporting and review to achieve transparency and accountability and ensure patient safety.
Unfortunately, this is not the end of the issue for Bacchus Marsh. We now await the review findings of the further seven baby deaths dating back to 2001. Sadly, it appears that more families have been affected by the tragic and unnecessary loss of life and will be reliving the trauma of their loss. We are also asking questions about the perinatal deaths that were deemed by Professor Wallace as unavoidable, and whether in fact this is the case.
What measures have been taken in order to prevent such events happening again?
A number of positive steps have been taken since these tragic events. First and foremost, the health minister has been frank and up-front about the deficiencies and the tragedy of these events. She has not sought to minimise or excuse the events nor gain any political mileage. The board of the hospital has been overhauled and there is a new CEO. This was essential not only to address the issue of the previous failed clinical governance, but also to help in restoring the community’s faith in the obstetric services at Bacchus Marsh. People need to see change and renewal. Professor Wallace also made some recommendations for state wide improvements of obstetric services.
For the seven families who lost their babies and whose deaths were found to be preventable, the health minister’s wish that a pragmatic approach be taken was honoured, and early offers of settlement were made by the hospital’s insurers without the need for further evidence. Some families have already accepted those offers and will again start a journey towards some kind of acceptance of what they have endured.
The government has also announced the creation of a new, ongoing role of chief medical officer in Victoria to look at strengthening hospital management and systems generally. Furthermore, a panel to advise and report on hospital and department improvements has also been announced.
People are usually asked to put trust and faith in doctors. Then, when such cases emerge, they create suspicion and concern. Should patients be more cautious?
We do need to put trust and faith in our doctors and health professionals. We have good reasons to do so in Australia as we boast high-quality and relatively affordable health care, which is the envy of many other countries. Without this trust the system wouldn’t work; there would be paralysis and necessary treatment missed.
However, such trust should not be blind. As patients, we are entitled to be active participants in our health care and so we should be wary of doctors who are unable or unwilling to explain a diagnosis, the pros and cons of proposed treatment, the risks and potential complications of surgery, medication or other treatment.
Doctors have a clear legal obligation to provide advice to patients about potential risks of treatment so that patients can make fully informed decisions about their treatment, including whether to consent to treatment. Gone are the days of “doctor knows best”. So patients should ask questions and not be daunted or rushed into anything.
Equally, we need to trust that doctors and medical professionals have many years of training and experience and the necessary qualifications to provide the relevant treatment, and to let us know if they don’t.
Some of the victims came from non-English speaking backgrounds. Is language a barrier in communication with doctors?
Language and cultural differences can act as barriers not only in discussions about treatment, but also understanding more generally about how the system works and the processes to be followed. For instance, there are cultural issues around resuscitation orders, end of life and the performance of autopsies when someone dies.
When it comes to patients whose first language is not English, additional steps might be needed. It will not always be sufficient or appropriate for a family member or friend to interpret. Depending on the circumstances and the seriousness of the condition and treatment recommended, a professional interpreter might be required. As far as Greek patients are concerned, fortunately, there are now plenty of well-qualified health professionals with Greek backgrounds who speak the language. Unfortunately though, some people conflate difficulties with the English language with a lack of intelligence or sophistication, and this might come out in the way they communicate.
As a lawyer with great experience in such cases, how do you perceive your role?
I enjoy the intellectual stimulation and investigative aspects of medical negligence work, piecing together what happened and what went wrong. It also allows me to combine my legal skills, while working with people and making a difference to many lives. It can be empowering for people to find out what happened to them or a loved one, and why, what their medical records say and what their potential entitlements are.
It is also rewarding to know that although we work on one case at a time, our work leads to improvements in medical care, which means improved safety for all patients and better outcomes overall. We are helping to effect change for the better.
How has your own Greek heritage and set of values affected your professional conduct?
As a second generation Greek, I have some understanding about how hard it can be for people to navigate unfamiliar concepts and systems. I used to help my grandmother, who was not fortunate enough to attend school, with her banking while I was at high school. I tailor my communication around people from diverse cultural and ethnic backgrounds, which doesn’t mean dumbing things down, but rather considering how best to directly communicate the issues so they fully understand their legal rights and advice.
My Greek heritage has instilled in me how fortunate we are to have opportunities to study and work in our chosen field, and to find success. But it has also highlighted the importance of fully utilising those opportunities, not wasting them or taking anything for granted. I grew up with a belief that nothing was out of my grasp and never felt like I didn’t belong or shouldn’t be at university, but certainly never with a sense of superiority or entitlement.