Key Takeaways
- The director general of WA Health will issue an improvement notice to King Edward Memorial Hospital following a report into the circumstances surrounding a baby "born dead" at the hospital.
- Doctors and midwives at the hospital will undergo new training as part of a cultural reform program.
- The report found failings in communication, teamwork, leadership, workload management, and a lack of situational awareness within the hospital’s labour birthing suite contributed to a multitude of breaches of policy during the baby’s labour and in the days that followed.
- The hospital’s primary fetal monitoring system, known as Phillips Intellispace Perinatal, was found to be not optimized and may lack the AI capability of other systems.
- The report made eight recommendations, including a major cultural reform program, boosting staffing levels, and reviewing the system used to monitor babies as they are being born.
Introduction to the Incident
The director general of WA Health will issue an improvement notice to King Edward Memorial Hospital and oversee an unprecedented cultural reform program following a harrowing report into the circumstances surrounding a baby "born dead" at the hospital. The report found that the hospital failed to follow its own policies, leading to the unnecessary death of the baby, Tommy Starkie. The baby’s mother, Alana Starkie, had traveled from Manjimup to Perth’s King Edward Memorial Hospital to induce labour when she was 38 weeks and six days pregnant. However, after more than four hours of labour, Alana realized there was something wrong and told the midwives she felt an agonizing pain she had not experienced during the births of her three other children.
The Report’s Findings
The independent panel behind the report found failings in communication, teamwork, leadership, workload management, and a lack of situational awareness within the hospital’s labour birthing suite contributed to a multitude of breaches of policy during Starkie’s labour and in the days that followed. The report found that the hospital’s staff breached policy on multiple occasions, including failing to perform a CTG immediately prior to labour, failing to interpret the CTG every half hour, and failing to document the CTG interpretations. The report also found that the hospital’s primary fetal monitoring system, known as Phillips Intellispace Perinatal, was not optimized and may lack the AI capability of other systems.
The Hospital’s Response
WA’s Director General of Health, Dr. Shirley Bowen, has apologized and admitted that the Starkies were failed, but was confident that King Edward Memorial Hospital was safe. The hospital’s chief executive, Robert Toms, has also apologized to the Starkie family and stated that the review identified eight contributing system factors and eight recommendations have been identified to improve these systems to ensure such incidents don’t happen again. The hospital has agreed to implement the report’s recommendations, including a major cultural reform program, boosting staffing levels, and reviewing the system used to monitor babies as they are being born.
The Family’s Response
Alana Starkie welcomed the report’s recommendations, but expressed concerns about how to fix a "broken culture" at the hospital. She stated that the hospital’s failure to follow its own policies led to the unnecessary death of her son and that no parent should have to go through the trauma and distress of holding their baby son while he dies in their arms. Alana’s husband, Paul Starkie, also expressed his concerns about the hospital’s culture and the need for change.
Conclusion
The report into the circumstances surrounding the death of Tommy Starkie at King Edward Memorial Hospital has highlighted the need for significant cultural reform at the hospital. The hospital’s failure to follow its own policies and the lack of situational awareness within the labour birthing suite contributed to a multitude of breaches of policy, leading to the unnecessary death of the baby. The hospital has agreed to implement the report’s recommendations, including a major cultural reform program, boosting staffing levels, and reviewing the system used to monitor babies as they are being born. It is hoped that these changes will prevent similar incidents from happening in the future and ensure that the hospital provides safe and high-quality care to its patients.