This report details the Office of the Health Ombudsman’s (OHO) investigation into Gold Coast University Hospital’s (GCUH) response to a number of adverse maternity events. In a hospital where nearly 5,000 babies are born each year without incident the number of adverse events were not statistically significant, however any single adverse event has significant and long lasting impacts on all parties involved.

From its opening in September 2013, GCUH experienced unexpectedly high demand within the maternity service. This affected the hospital’s capacity to adequately implement processes and frameworks that would normally be expected in level 5, transitioning to level 6, maternity service. This demand occurred against a background of issues already identified and recommendations made in numerous reviews of GCUH maternity services and its predecessor, the Gold Coast Hospital (GCH) Birth Centre, between 2010 and 2015.

Issues

The OHO began its investigation in December 2014. In investigating the adverse maternity events, the OHO identified key systemic issues with Gold Coast Hospital and Health Service’s (GCHHS) response to the events, rather than the quality of the maternity service provided. Consequently, the scope of the investigation—and this report—was distilled to consideration of the following issues:

1. why some adverse outcomes had recurred, despite several internal and external reviews highlighting areas of risk mitigation that would assist in preventing adverse outcomes
2. GCHHS’ systems and governance structures to record and monitor the processes of making and implementing recommendations for improvement, both internal and external, including escalation processes to address issues where recommendations have been implemented and the issue recurs
3. GCHHS’ governance arrangements in place to ensure timely reporting of adverse maternity events, including effective reviews of maternity data to identify trends requiring remedial action.

Findings

The OHO’s investigation produced a number of relevant findings; many of these are now historical, as GCHHS independently and proactively addressed identified weaknesses in its clinical incident management framework and safety and quality governance structure. The OHO’s findings were:

1. GCHHS undertook limited evaluation of the impact implementing a recommendation had on the issue it was targeted to address. This resulted in the same or similar issues recurring, which was compounded by the complex safety and quality governance structure for the maternity service.
2. GCUH had insufficient systems in place to ensure consistent management of obstetric patients who presented to GCUH outside of the maternity service e.g. within the emergency department. This issue had been ongoing since 2014.
3. GCHHS had an overly complicated safety and quality committee structure for the maternity service. This structure lacked focus on its goals and did not support strong accountability nor oversight of trends, risks, recommendation implementation, the escalation of repeating risks and other key elements required for a robust safety and quality structure.
4. GCHHS did not have a comprehensive recommendation tracking system, enabling safety and quality committees to see maternity recommendations at any point in time, including their implementation status. This led to an overly optimistic assessment of how implementation was effected and whether a recommendation should be closed as having been fully implemented.
5. GCHHS needed to utilise trended incident data better to drive process improvement from the higher level safety and quality committees through the chain to the service line level. This includes continuing to improve GCHHS’ approach to classifying incidents to ensure that they are appropriately captured and categorised in order to inform decision-makers about trends in the maternity service.

Actions by Gold Coast Hospital and Health Service

Since 2016–17, GCUH has performed strongly against national benchmarks and clinical indicators for maternity services, which further demonstrates that GCUH has a safe maternity service. The OHO finds GCUH’s current focus on revising its clinical incident management framework is appropriately targeted, as this is where there are opportunities to continuously improve. Measures already implemented by GCHHS in this area include:

• revising the safety and quality committee structure
• introducing stronger collaboration and referral between the emergency department and maternity service
• use of trended data to drive safety and quality improvements
• greater emphasis on timely implementation of recommendations to, as far as practicable, prevent incidents recurring.

The clinical incident management framework and safety and quality governance approaches being implemented at GCUH may serve as a model worthy of adoption by other tertiary maternity services in Queensland.

Recommendations

GCHHS has already begun planning and implementing measures to address the issues identified in the OHO’s investigation. The OHO’s recommendations are therefore framed to allow the office to evaluate the effectiveness of the measures implemented to ensure that they are responding to the key concerns outlined in the complaints. This enables the OHO and GCHHS to collaborate and share information, perspectives and experience to further refine a high quality and safe maternity service.

This report makes eight recommendations around:

• evaluating the appropriateness of measures implemented to support the management of pregnant women in the emergency department
• ensuring the effectiveness of the midwifery navigator roles
• evaluating the adequacy of the clinical incident management framework following implementation of measures after the internal review of the framework is completed
• increasing the independent verification by high level safety and quality governance committees of the information provided by the committees below
• continuing to improve the use of trended clinical data to drive process improvement in the maternity service
• improving the transparency of the safety and quality environment of the maternity service through a yearly public report.

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

For media: Read the media statement