UPDATE: THE former director of obstetrics at Bacchus Marsh and Melton Regional Hospital had conditions placed on his medical licence after an investigation that found the deaths of seven babies may have been avoidable.

Director of obstetrics and gynaecology, Surinder Parhar, retired from the Djerriwarrh Health Services, which looks after the hospital, in July this year.

He had been at the hospital for 30 years.

Conditions were placed on his medical licence in June following a 28-month investigation by the Australian Health Practitioners Regulatory Authority.

This investigation resulted from a doctor lodging a complaint. It is understood Mr Parhar has left the country.

The Herald Sun is not suggesting Mr Parhar was directly involved in the deaths.

In what Health Minister Jill Hennessy today described as a “catastrophic event”, an investigation into Djerriwarrh Health Services found seven of 10 stillborn or newborn deaths in 2013 and 2014 may have been avoidable.

Five babies died in 2013, and two in 2014.

The investigation, held by Professor Euan Wallace, found a “number of key failings at Djerriwarrh Health Services during 2013 and 2014”.

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Despite the high number of deaths the hospital, nor its staff, ever raised an alert.

This issue came to light when a group of senior clinicians on the Consultative Council of Paediatric Mortality and Morbidity were reviewing data when they noticed an unusually high number of deaths.

Australian Nurses Federation secretary Lisa Fitzpatrick said midwives had raised concerns over practices at the hospital and claims they were not listened too.

“Staff are very distressed and disturbed at what’s happened and there also relieved because we know our members here have been raising concerns about clinical risk and we passed those concerns onto the previous hospital’s executive,” she said.

“We also put those concerns in writing to the Department of Human Services and they’ve felt their concerns have been dismissed and not taken seriously.

“People want to make sure that what has happened never, ever happens again to any woman or family in this state ever again.”

Ms Fitzpatrick said staff raised concerns about the profile of some of the women giving birth at the regional hospital.

“They were concerned about the lack of consistency of obstetric and paediatric cover for women birthing here earlier than 37 weeks,” she said.

“They have declared themselves to be a level three maternity service so when you’re having premature babies here at 34 weeks, in particular when many of these women had serious medical conditions themselves, they believed they should have been at a tertiary maternity unit.”

The hospital’s administration has been replaced, while its obstetric services are being overseen by tertiary hospitals.

A further investigation has been launched to determine if the Department of Health should have realised the tragedy earlier.

“What has happened here has been a series of catastrophic failures by a number of parties that may have contributed to the very sad loss of young life,” Ms Hennessy said.

“In 2013/14 there were seven peri-natal deaths at Djerriwarrh — that is double the number expected, yet this was overlooked by the clinical leader and the board of Djerriwarrh.”

media_camera Health Minister Jill Hennessy at today’s press conference. Picture: Hamish Blair

Ms Hennessy said the “shocking failures” at the hospital included inadequate reviews of peri-natal deaths.

“While Djerriwarrh did review some of the deaths at the time, it did not review them all. And while some were reviewed, they were inadequate and the findings were not always actioned,” she said.

The board was not told of some deaths, and there was poor oversight.

Other failures included staff misreading and misusing foetal surveillance, and the acceptance of high-risk pregnancies that should have been referred on.

Ms Hennessy said the hospital had “failed to adjust or update its practices to respond to rapid population growth in the region”, but she defended government investments in the health service.

She said some deliveries should not have been attempted at a service classified as a low-risk provider, and that staff were inadequately trained.

Australian Nursing and Midwifery Federation Victorian secretary Lisa Fitzpatrick said concerns about a lack of staff, policies and equipment at Djerriwarrh’s maternity services were raised with the Health Department in 2014.

“Some midwives, and possibly doctors, had raised concerns with management and left the service in frustration when their concerns weren’t addressed,” Ms Fitzpatrick said.

“We know that there were an increased number of births at the service and this was not proportionately matched by increased staff or infrastructure.”

Dr John Ballard, who was appointed to the Djerriwarrh board to oversee the hospital in the wake of the deaths, said they resulted from “multi-system failure” and there was not one doctor common to each case.

media_camera Bacchus Marsh and Melton Regional Hospital. Picture: Nicole Garmston

Ms Hennessy said it was a “truly heartbreaking set of circumstances”, and full support would be given to the families involved.

She said the investigation would be transparent because the families deserved to know the truth about the “shocking failure”.

The affected families may be eligible for compensation.

“I am deeply conscious that nothing can change the past for these families,” Ms Hennessey said.

Ms Hennessy said the impact of the scandal was unimaginable for women already grieving over the loss of their babies.

“After these women endured the death of their babies, in some circumstances they weren’t given the information that they sought,” she said.

“It is heartbreaking to think of these women thinking that for some reason the death of their baby may have been their fault.

“It is absolutely critical that we are able to get every piece of information around their pregnancies and the births and have that peer reviewed.”

Senior staff from the Royal Women’s Hospital have been sent to Djerriwarrh to provide expert oversight and better clinical training for staff.

Principal at Maurice Blackburn Lawyers Dimitra Dubrow told 3AW two families had contacted the firm about the deaths of their babies.

“What they are telling us ... is that they have been contacted by the Department of Health and advised that the circumstances surrounding their baby’s death is being looked into and that the death may have been prevented.

“You can imagine this would be extremely distressing for these families who have already suffered a painful loss.”

The Australian Health Practitioner Regulation Agency said Mr Parhar had been investigated after a complaint in 2013 about his care of a mother after the stillbirth of her baby at the hospital.

Action was taken against the doctor imposing conditions on his registration requiring education and mentoring.

“At the time, AHPRA and the boards were not advised of abnormally high peri-natal mortality rates at the health service, or about any concerns about that doctor’s care of other patients, or concerns about the quality of obstetric or midwifery care provided at the Djerriwarrh Health Service,” the statement reads.

AHPRA said the case was not sent to a tribunal because it did not meet the threshold for referral.

CEO Martin Fletcher apologised for the time taken to investigate the complaint about that doctor.

Mr Parhar surrendered his registration on October 1.

AHPRA said it was now launching a wider investigation into other doctors and midwives at the Djerriwarrh Health Service.

“In late July 2015, AHPRA, the Medical Board of Australia and the Nursing and Midwifery Board of Australia first learned of wider concerns about potentially avoidable peri-natal deaths at the health service.

“Immediately, AHPRA used its powers to require the Djerriwarrh Health Service to provide information to enable close regulatory scrutiny of care provided by registered health practitioners at the service.”

It is believed the hospital received significant government funding to help expand maternity services just a year ago.

More than $740,000 was directed towards the maternity services unit in 2014.

The hospital’s maternity services birthrate had doubled in less than a decade.

According to the 2013/14 annual report, 897 babies were born in the maternity unit in that year.

In the 2012/13 financial year, 1016 babies were born and 914 born in the year before that.

It was expected the hospital would be catering for up to 1400 births a year as a result of the expansion.

With AAP

grant.mcarthur@news.com.au