Report into four Adelaide babies’ deaths recommends better communication, but not ECMOs


An independent report into the deaths of four babies at Adelaide’s Women’s and Children’s Hospital has recommended improvements to communication between its medical staff and with interstate hospitals.

The babies died in September and October, and clinicians told a parliamentary committee a lack of cardiac services at the hospital may have contributed to their deaths.

The report, released today by SA Health on Christmas Eve, found only one of the babies may have benefited from using an external oxygenation machine (ECMO).

The five-day-old baby died before he or she could be transferred to Sydney for treatment.

The report recommended improvements to communication to “establish clear roles and responsibilities for each clinician involved in the care plan” and a review of communication between hospitals.

SA’s Deputy Chief Medical Officer, Mike Cusack, said he hoped the review would provide the families of the babies some closure and assurance that their children got the best available care.

But he acknowledged there was also room for improvement.

“We are … always keen to learn and improve, and I think this was an opportunity where we have recommendations and we really have an opportunity to implement those and improve upon the care in which we provide,” Dr Cusack said.

“My heart really goes out to the families of the babies. This must be a desperately difficult time for them.

‘No evidence’ pandemic affected outcomes

A business case prepared by a group of doctors last year claimed the lack of paediatric cardiac services at the Women’s and Children’s Hospital contributed to at least one avoidable death and several near misses at the time.

It called for the establishment of an external oxygenation machine (ECMO) life support service at the hospital.

Professor John Svigos has been critical of the hospital’s leadership.(ABC News: Alina Eacott)

Mining magnate Clive Palmer offered to buy five ECMOs, but the offer was rejected by the State Government.

Today’s report found the machines “would have been very unlikely to increase the chance of survival of any of the babies”.

Obstetrician Professor John Svigos, the convenor of a group called the Women’s and Children’s Hospital Alliance, said he had “an overwhelming sense of sadness” at reading the “heavily redacted” review and said it was “tactless” to release it on Christmas Eve.

He said the “generic” recommendations did not go far enough.

The report found there was “no evidence that [the] COVID–19 pandemic had a significant impact on the outcomes” of the babies, since they could have gone to Sydney’s Children’s Hospital at Westmead instead of the Royal Children’s Hospital Melbourne.

Melbourne’s coronavirus outbreak at the time led to State Government restrictions that prevented people who had been to Victoria returning to South Australia.

An unidentified staff member and baby at Adelaide's Women's and Children's Hospital.
Three of the babies had heart problems and the fourth suffered from a severe infection.(Women’s and Children’s Hospital)

‘Unclear’ if all staff understood babies’ care plans

The review said it was “unclear” whether all the clinicians involved in the four babies’ care fully understood the babies’ care plans and the lines of responsibility for their treatment.

A bald man wearing a suit
Mike Cusack says SA Health will work to implement all of the recommendations.(ABC News)

“From the review of the clinical notes, it is unclear whether all of the clinicians involved in the care of these neonates had a shared understanding of the care plan and lines of responsibility,” it said.

“Documented case conferences would have supported communication and clinical leadership.”

It said while there were “sophisticated” transfer systems within the state, “standardised national protocols for the transfer of babies should be developed by neonatal retrieval services and children’s hospitals”.

Dr Cusack, who is also one of the state’s Deputy Chief Public Health Officers, said SA Health would work to implement all of the recommendations, including on how documentation flows between hospitals.

“The review also makes a point in relation to the multidisciplinary team and how surgeons in another hospital can be brought into the multidisciplinary team,” he said.

“Obviously, with technology as we have available now, we can really bring people — even though they’re in another hospital — we can bring them into the room through Teams and through Zoom so those really critical conversations are happening.”



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