The mother was transferred to a tertiary hospital and we immediately commenced an internal review to determine the cause or any contributing factors.
The group undertaking the review commenced investigation of a possible serious clinical error.
St John of God Health Care, including St John of God Bunbury Hospital, considers patient safety our highest priority and we have processes and policies in place to deliver high quality clinical care.
In situations like this, which are fortunately rare, we undertake a full investigation, including a root cause analysis, to identify whether or not policies and processes have been correctly followed.
Root cause analyses at St John of God Health Care are conducted by a group comprising internal staff members who are deemed to have specialist expertise and are able to conduct an impartial investigation, as well as external expertise, as required.
The investigation and review are still ongoing but based on the available information at this time it appears that the incident was caused by human error.
Notwithstanding this, we have put in place a range of actions in response to this issue. This include additional training, review of policies, review of handover processes and protocols, and review of our medication inventory management.
As per normal process during an investigation like this, we have stood down staff members who were involved. The incident was reported to the Australian Health Practitioner Regulation Agency (AHPRA) who have suspended the registration of a midwife involved . The other staff member involved has resigned.
We have kept the family informed and updated throughout this process.
This is a tragic occurrence. The hospital feels deeply for the family and will continue to investigate.