The following relates to a complaint made to the Health Quality and Complaints Commission (HQCC – Queensland’s health complaints agency from 2006 to 30 June 2014) in 2013 by an obstetrics patient who had a stillbirth at the Townsville Hospital Birth Centre (THBC).

The complaint called into question the quality of healthcare provided to her by Townsville Hospital and Health Service (THHS) and two registered midwives.

As part of its investigations into the matter, the HQCC considered evidence from:

• the complainant
• THHS
• the two registered midwives
• two independent practitioners, who specialise in obstetrics and gynaecology
• the THBC’s root cause analysis (RCA)
• THHS’s relevant maternity and neonatal clinical guidelines.

The HQCC released a draft investigation report, including preliminary recommendations, in June 2014 highlighting a number of matters concerning:

• systemic issues related to the communication of patient information between multiple health facilities within the THHS
• multiple failures on the part of both midwives to adhere to proper procedures.

After reviewing and analysing the evidence, the Health Ombudsman determined:

• that the THHS has appropriately considered and complied with the recommendations outlined in both the RCA and the HQCC’s draft report
• that the THHS has successfully undertaken suitable measures to enhance quality of care to patients
• no grounds to warrant serious misconduct in relation to the performance issues raised against the two midwives.