A review is underway into the deaths of four babies within a month at Adelaide's Women's and Children's Hospital amid concerns a lack of specialist cardiac surgery facilities may have contributed.
Deputy Chief Public Health Officer Michael Cusack says such a cluster of cases over a short period of time is concerning.
He said the hospital would expect to report only six to 10 such cases, of very young infants with serious heart problems, each year.
"Where we see four babies in a cluster, that is a cause for further investigation," Dr Cusack said.
"As a parent, whenever you read about adverse events in children, it's always hard.
"So my heart really does go out to each of the parents and families that have been affected by this.
"When you see these tragic events there's a great need and desire in the health system to want to analyse and really understand what happened."
Dr Cusack said investigations already conducted by the hospital had not identified any particular problems or mistakes with the treatment of the babies.
His review would focus on whether the best care for such cases was available in SA.
"Is there anything, that if a child were to present with similar circumstances in the future, that we may be able to do differently next time," Dr Cusack said.
The review is expected to be completed in two to three weeks with a briefing to go to Health Minister Steven Wade.
Adelaide Women's and Children's hospital Source: Google
Mr Wade said a recent report to the board of the Women's and Children's Hospital had concluded that establishing a full cardiac surgery unit in Adelaide would increase the risk to seriously ill infants because of low case numbers.
But he said the hospital's board was seeking further information and input from other senior clinicians on that issue.
The hospital was also working to establish an Extra Corporeal Membrane Oxygenation (ECMO) support service, which replaces the function of the heart and lungs, the minister said.
Under current arrangements, young infants needing complex cardiac surgery in South Australia are flown to Melbourne, although COVID-19 restrictions have resulted in patients being sent to Sydney in recent months.
Details of the four deaths were revealed to a SA parliamentary committee on Tuesday.
Obstetrician John Svigos told the committee Adelaide was the only mainland capital that did not perform paediatric cardiac surgery.
He said he was aware of three deaths in the past four weeks, while Salaried Medical Officers Association industrial officer Bernadette Mulholland said there had been a further death last week.