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Doctors' repeated warnings about lack of W&CH cardiac care went unanswered


Doctors at the Women’s and Children’s Hospital say “bureaucratic” and “clunky” reporting systems must be improved after their warnings were either rejected or left unanswered before the recent “avoidable” deaths of four babies.

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Women’s and Children’s Hospital paediatric intensive care medical unit head Dr Michael Yung told ABC Radio Adelaide this morning that a “comprehensive” business case was presented to the hospital’s board in July last year addressing the absence of a cardiac surgery unit and an ECMO machine, but that plan was “still under consideration”.

He said doctors also tried to submit reports to SA Health’s Safety Learning System (SLS) about the babies’ deaths this year, but were advised that because the hospital does not have a paediatric cardiac service “there’s nothing to report”.

He said doctors were subsequently advised to log their concerns on the hospital’s risk registry, but despite meeting with authorities in July to discuss their application, no action was taken.

The doctors’ union and a prominent obstetrician revealed at a parliamentary committee earlier this week that the four babies had died at the WCH in the past four weeks because of a lack of cardiac surgery unit.

Adelaide is the only mainland capital city without a paediatric cardiac surgery unit or ECMO service.

Sick babies and children have been required to fly to Melbourne for life-saving heart services, but COVID restrictions have hampered that and they now have to go to Sydney.

The reason for the rejection was that we don’t have the systems in place, therefore, there’s nothing to report

The sudden deaths of the babies – described by the Government as a “cluster” – prompted SA Health to yesterday launch an urgent review.

“We were hoping to address it (the lack of cardiac services) by producing this business case and saying ‘look, here’s a problem, here’s a solution – help us do this,” Yung said.

“(That) is still under consideration by the board.

“We have submitted to the SLS – the Safety Learning Systems – some reports about what we thought were avoidable deaths due to the lack of these services, but they’ve been rejected.

“The reason for the rejection was that we don’t have the systems in place, therefore, there’s nothing to report.

“We were advised rather than reporting each case, register on the hospital’s risk registry and we had a couple of meetings back in July about that, but to date that still isn’t on the risk registry.

“I don’t understand why but it’s not.”

A report to SafeWork SA by the South Australian Salaried Medical Officers Association – seen by InDaily – states the doctors’ SLS reports were rejected on a technicality because “there is no safety issue if there is no service”.

The report states that if no SLS report is made, the Health Minister is not advised of the issue.

WCH paediatric intensive care specialist Dr Steve Keeley told ABC Radio Adelaide that the hospital’s reporting systems were “overly bureaucratic” and “clunky”.

“The purpose of the Safety Learning System is to point out to our administration and then through them I would hope to the Government that there are inherent weaknesses in the system of care that we’ve got for these very vulnerable children – these children who are the sickest of all children we look after,” he said.

“The last month has really brought these risks to the fore unexpectedly and very sadly and for all of us it’s not something now for us to say ‘well this is the system that we have’.

“We must do something better.”

InDaily asked SA Health why authorities did not respond to the doctors’ business case, SLS reports or risk registry applications.

A spokesperson said the Chief Medical Officer would conduct a review into the circumstances surrounding the treatment of the four babies at the hospital, including whether COVID-19 and related restrictions had any impact upon their care.

“The health and safety of all our patients is our highest priority,” the spokesperson said.

“The treatment decisions are always clinically-based and are made by the treating clinicians.”

We are not playing with the lives of babies here in South Australia

Keeley said the doctors’ business case was “the best solution for the children in South Australia”.

But Premier Steven Marshall told reporters this morning that expert advice provided to the Government was that babies could be placed at more risk if South Australia funded its own paediatric cardiac service.

“Because the demand (for paediatric cardiac services) in South Australia is low, the volume is low (and) it’s sub-scale, we wouldn’t be, in fact, reducing the risk, we would be enhancing the risk,” he said.

“The people who are giving that expert, independent advice do not come from jurisdictions that are involved in the services that we provide in South Australia – I think there’s one health professional from Queensland and two from Auckland.”

Marshall said he “fully appreciated” that some clinicians had differing opinions.

He conceded that the Government does “need to be constantly looking at that advice and making sure that it is independent and the best advice”.

“We are not playing with the lives of babies here in South Australia,” he said.

“We are not making political decisions.”

Former chief executive at Melbourne’s Royal Children’s Hospital John De Campo told ABC Radio Adelaide that “you do need volume to get great outcomes for babies”.

“The best outcome in cardiac surgery is at a place where they do five a day – not five a month,” he said.

“That’s why in smaller states babies are sent to places where they’ve got world-class outcomes and we don’t need to practice in South Australia.”

It comes as Victorian Premier Daniel Andrews said yesterday that his government did not prevent the babies from being treated in Melbourne.

“I want to send my sympathies to those parents… this will be a very difficult time for them,” he said.

“But I don’t think it was a matter of restrictions.

“There was a choice – not at our end, but at the other end – for them not to be sent here.”

Marshall said the Government’s review would determine why the babies were unable to travel to Melbourne.

“Three of the cases were cardiology-related, one was with regards to the transfer of the mother, but I’m not 100 per cent sure it’s really appropriate for me to be going through the details of these cases, especially because they will be subject to an internal mortality review, an external coroner’s review and now the Deputy Chief Medical Officer doing his review in terms of that overall cluster,” he said.

“What we’re dealing with here is an absolute tragedy (and) what we’ve got to be sure of is that any action that we take improves the service that we offer babies in South Australia.”

Opposition Health spokesperson Chris Picton said the Government’s review needed to be expanded to cover any other deaths of cardiac patients at the Women’s and Children’s Hospital and also to investigate why the doctors’ SLS reports were rejected.

“It is absolutely shocking that doctors were being silenced by bureaucrats in their attempt to report safety concerns and patient deaths,” he said.

“This investigation must be broader – we must get a full inquiry into any other deaths that have occurred over the past year, and investigate who was silencing these doctors from raising the alarm over safety.”

Federal Health Minister Greg Hunt described the four babies’ deaths as “the worst imaginable of all things” and an “agonising situation”.

“I know it’s being treated with the upmost gravity by South Australia,” he told the ABC.

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