DJERRIWARRH HEALTH SERVICE UNDER THE SPOTLIGHT:
THE HOSPITAL
* A low-risk maternity service in a booming population area in western Melbourne
* Staff not trained for more complex pregnancies
* Clinical governance not good enough to respond to problems in a timely manner
THE DEATHS
* 11 deaths since 2013, seven judged to be avoidable
* Concerns around staff ability to monitor fetal heart rates
* Women with high-risk pregnancies should have been sent to other hospitals
THE DOCTOR
* Surinder Parhar worked for 30 years in Victoria and ran Obstetrics at Djerriwarrh
* He was investigated for 28 months after a complaint from another doctor, whose patient lost a baby
* Dr Parhar had conditions put on his licence to practice in June 2015, and he retired in July
* A review found no one doctor was involved in all the deaths
THE REVIEW FOUND
* Staff misused or misinterpreted fetal surveillance by cardiotocography (CTG)
* Lack of out-of-hours paediatric cover for neonatal resuscitation and care
* Lack of high quality staff education
THE RESPONSE
* Royal Women's Hospital senior midwife seconded to Djerriwarrh
* Full review of all women due to deliver at Bacchus Marsh and Melton
* New intensive staff training, new fetal monitoring system, more clinical reviews, weekly maternity unit meetings
* All maternity services state-wide must review any perinatal death
* Recruitment under way for new Director of Obstetrics and Gynaecology.
Sources: Executive summary from the Report of an Investigation into Perinatal Outcomes at Djerriwarrh Health Services by Professor Euan M Wallace. Victorian government.
