This report details the Office of the Health Ombudsman’s (the office) investigation into the safety and quality of maternity services across the Central Queensland Hospital and Health Service (CQHHS). The report presents the findings of a systemic investigation that began following several adverse incidents within the region.

CQHHS provides health services across a catchment area that is almost double the size of Tasmania with half the population. Providing services over this geographical expanse is challenging yet CQHHS currently consistently provides safe and quality maternity services and the communities serviced should feel confident in the care they are receiving. CQHHS has been on a journey to reach this level of safety as in 2015 and 2016 the task of delivering safe and high quality services across the CQHHS catchment appeared challenging with major safety and quality issues occurring in the Rockhampton and Gladstone Hospital maternity services during this period.

CQHHS independently commissioned internal clinical reviews of five maternity services across Central Queensland which were completed between February 2017 and March 2018. In October 2018, the office commenced an own motion systemic investigation into the same five maternity services, namely Rockhampton, Gladstone, Emerald, Biloela and Theodore. This investigation enabled the office to address any outstanding concerns holistically and to support CQHHS on its journey of continuous improvement.

Issues

The scope of the investigation—and this report—was refined to seven key themes:

1. Safety and quality governance
2. Clinical incident management
3. Classification and identification of maternal risk and subsequent escalation
4. Liaison between emergency and maternity
5. Models of care
6. Staffing and skills mix
7. Culture and communication.

In addition, the following unique issues were identified:

• Gladstone hospital: leadership across the health service, including role modelling of an appropriate safety and quality culture.
• Emerald hospital: historical issues identified in relation to ensuring that women are at the centre of care decisions and not negatively impacted upon by internal cultural issues.
• Theodore hospital: maintaining a Level 1 maternity service.

Findings and Recommendations

The office’s investigation produced a number of relevant findings and recommendations which have been broken down into the relevant maternity service and CQHHS overall. The CQHHS Board are clearly engaged with safety and quality governance improvements and have contributed to turning around the maternity services to ensure that they are safe and support high quality outcomes for mothers and babies across Central Queensland

Rockhampton Hospital maternity service

Rockhampton Hospital maternity service is the sole Level 4 service within CQHHS and has performed strongly against national benchmarks. It has made significant strides in the last three years and demonstrates a genuine commitment to providing a safe and high quality maternity service. The office’s main investigative findings were:

• Maternity risk assessing is embedded into the culture of the maternity service, evidenced by a lack of serious incidents involving risk assessing as a contributory factor.
• The midwifery group practice model of care continues to expand.
• Staffing has stabilised with a full complement of permanent obstetricians and there is greater clarity and support in midwifery staffing.
• Significant cultural improvements have been implemented to transform the service.

The office has not made any recommendations and believes that the maternity service has the strategic and operational capability to continue on its journey.

Download the Rockhampton Hospital report

For media: Read the Rockhampton Hospital media statement

Gladstone Hospital maternity service

Gladstone Hospital maternity service is the busiest Level 3 public maternity service in Queensland and performs within the expected ranges when benchmarked against its peers. Since June 2018, the service has started to address the challenges it faces, enabling it to refine and improve clinical governance and safety and quality processes. The service has made even greater strides in improvement since a change in executive leadership at Gladstone Hospital in late 2018.

The office’s main investigative findings were:

• Improvement is necessary in the categorisation and assessment of maternity risk.
• There is room for refinement in the collaboration between the emergency department and the maternity service.
• Recruiting skilled staff remains a challenge. This is being addressed through current recruitment processes.
• Leadership will need to role model the importance of safety and quality governance and processes.

This report makes four recommendations around three themes:

• Assessment and management of maternity risk
• Triaging pregnant patients in the emergency department
• Benchmarking the safety and quality leadership to identify key areas for improvement.
• The Gladstone Hospital maternity service has the necessary focus to progress this change and will be adequately supported by the CQHHS executive.

CQHHS accepts all of the recommendations made by this office and has already commenced implementation.

Download the Gladstone Hospital report

For media: Read the Gladstone Hospital media statement

Biloela Hospital maternity service

The Biloela Hospital maternity service is a Level 3 public maternity service and services a large and remote area. It is clear that Biloela Hospital is committed to improving and refining its service despite the resourcing challenges it faces. The office’s main investigative findings were:

• The safety and quality governance structure needs to be streamlined.
• The maternity service is trying to improve the options for women by introducing shared care and a midwifery group practice.
• Staffing has stabilised, but recruiting skilled staff remains a challenge.
• There is a supportive culture committed to making the necessary improvements.

This report makes one recommendation:

• Streamlining the committee structure which is aimed at limiting the gaps in the governance chain where issues have the potential to fall through.
• The Biloela Hospital maternity service can be further supported by a clearer approach to clinical governance and demonstrates a commitment to providing safe, high quality maternity services.

Download the Biloela Hospital report

For media: Read the Biloela Hospital media statement

Emerald Hospital maternity service

The Emerald Hospital maternity service is a Level 3 public maternity service and provides services to women from a range of remote locations. The Emerald Hospital maternity service has demonstrated an increased focus on clinical governance with stability in the executive leadership which has led to improvements in safety and quality. The office’s main investigative findings were:

• The embedding of robust clinical governance processes needs to remain an area of focus for the maternity service and executive leadership.
• The new hub and spoke model of care with Rockhampton Hospital has improved clinical outcomes for patients.
• Recruiting skilled staff remains a challenge.
• A number of cultural initiatives have been introduced to improve relationships between midwives and medical staff, resulting in significant improvements. There is still room to continue these improvements.
• When an internal review identified that women did not feel at the centre of care decisions, the maternity service implemented a consumer engagement strategy which has transformed the service.

The Health Ombudsman did not consider it necessary to make any broad recommendations but the report makes one technical recommendation:

• An audit of all epidurals since the last audit and an action plan for any identified areas of improvement as a result.
• The Emerald Hospital maternity service has made significant improvements in a short period of time and has made brave decisions about their model of care which supports safe and high quality outcomes for women and babies.

Download the Emerald Hospital report

For media: Read the Emerald Hospital media statement

Theodore Multipurpose Health Service

The Theodore Multipurpose Health Service is a Level 1 maternity service which had previously been a Level 2 maternity service prior to flooding in early 2011. An internal review by CQHHS identified major gaps in the capability of the Level 1 maternity service and during discussions between the staff from this office and representatives from the Theodore community, it was clear there had been a lack of community consultation about the decision to maintain Level 1 maternity services.

The office’s main investigative findings were:

• The implementation of the recommendations made by the internal review have yet to be commenced and should be prioritised.
• The current model of care does not support a contemporary Level 1 maternity service and any redesign of the antenatal and postnatal care options should be undertaken in close consultation with the community.
• There was no community consultation about the decision to maintain a Level 1 maternity service, leading to friction between CQHHS and the community.

This report makes one recommendation:

• The office will retain oversight of the implementation of the internal review recommendations to ensure they are completed in a timely manner.

The Theodore Multipurpose Health Service and CQHHS are committed to ensuring that the necessary work is undertaken to ensure a reliable, safe and high quality Level 1 maternity service.

Download the Theodore Multipurpose Health Service report

For media: Read the Theodore Multipurpose Health Service media statement

CQHHS

In investigating the various maternity services across CQHHS it became clear that overall the Board and its committees are soundly fulfilling their role as the strategic leader of CQHHS but that there were some ongoing areas for refinement to continue the sophistication and maturity of the governance and oversight processes in place across CQHHS.

CQHHS accepts all of the recommendations made by this office and has already commenced implementation. CQHHS Chief Executive Officer Steve Williamson said that the report’s findings were welcomed by CQHHS and reaffirm the actions already begun by the maternity services.

Download the CQHHS oversight of the maternity services report

For media: Read the CQHHS oversight of the maternity services media statement

Download the list of investigation documents