Inadequate care at the Mackay Base Hospital contributed to the deaths of three babies and many women suffered lifelong physical and mental harm, a shocking investigation into the hospital's obstetrics and gynaecology service has found.
Queensland Health Minister Yvette D'Ath was close to tears on Friday as she outlined the deaths of the three babies, spanning over a decade.
"No family should ever have to experience the devastation of the loss of a child and certainly not under these circumstances," she said, as she outlined shocking details contained a 10-month review of the service.
"To all the women and their families who have been impacted by these failings, I offer my sincerest, unreserved apology.
"I am deeply sorry for the harm that has been caused to you and your family.
"Our health system can, and must, do better."
Ms D'Ath thanked more than 170 women who forward after the review was announced in October last year.
"You've shone a light on failings that have been hidden for far too long," she said.
The investigation team found multiple examples of substandard care, poor clinical incident monitoring and poor management of safety and quality, patient complications and clinical deterioration.
"The report is damning in its identification of failings at multiple levels within Mackay Hospital and Health Service, and more particularly, the Mackay Base Hospital," Ms D'Ath said.
"Of the 81 women who bravely came forward and were interviewed by the investigation team, the report notes that many of these women have sustained lifelong physical and mental harm.
"This findings is deeply distressing and the significant adverse impacts on the lives of women and their families who entrusted their health care to the Mackay hospital is unforgivable.
"We owe it to the women who have come forward as part of this investigation to make improvements to clinical governance here in Mackay and elsewhere across the state."
'The report is damning'
Women told the investigation team they were ignored, disrespected, neglected, left in pain and were discharged back to their general practitioners with incomplete resolution of their problems and not adequately followed up by the Mackay Base Hospital.
"The team was often brought to tears," Ms D'Ath said.
"Many women described the experience of being interviewed as part of the investigation as the first time they felt heard."
Ms D'Ath added: "The report is damning."
The review team said the responsibility for oversight of clinical services in obstetrics and gynaecology at the hospital rested with "various personnel".
"Those personnel should have been more alert to the complications in O&G care that were happening, should have been integral to the safe management of them and investigated and intervened much earlier than was ultimately done to prevent further harm to women," the team wrote in its report.
"The issues identified speak to a problematic workplace culture at many different levels, with different contributors and unless those are identified and fixed, similar problems are likely to occur in future."
"The Investigation Team found that systematic failures at all levels throughout the organisation allowed poor practice and bad behaviour to flourish, making O&G care at Mackay Base Hospital less safe."
Clinicians referred to Health Ombudsman
Ms D'Ath said the investigation team heard that women felt ignored, left in pain and were discharged back to their general practitioners with incomplete resolution of their problems.
She said that 26 cases fell below the expected standards, causing personal injury or harm and have been advised of a compensation assessment pathway.
Ms D'Ath said four clinicians had been referred to the Office of the Health Ombudsman as a result of the review.
She said none of them were still employed by Queensland Health.
The minister said she had issued a show cause notice to the Mackay Hospital and Health Service board in light of the review’s findings.
She said board members had until next Friday to respond as to why they should not be dismissed.
'No trust, women travelled to other hospitals'
The review, which began on November 1 last year, investigated maternity and gynaecological outcomes at the hospital between July 1, 2019 and October 31, 2021.
The report found many of those interviewed as part of the review were seeking care outside of the Mackay Hospital and Health Service "due to the lack of trust" they had developed in "The Base".
"This is creating a financial burden for many of them travelling to Townsville and Brisbane to receive the care they need," the reviewers said.
"Since the investigation was announced, women who contacted the consumer feedback line were offered psychological support, with women taking up that offer, whilst others explained they do not have faith in that system either.
"Others were just trying to forget their experience and move forward."
The report identified a failure by the Mackay hospital to investigate issues that were arising with obstetrics and gynaecology, particularly after October 2020.
"When trainee doctors and midwives tried to raise concerns in relation to consultant behaviours, clinical practice and outcomes, their concerns were dismissed by senior staff."
The reviewers said clinical incident monitoring during 2021 was "problematic and incomplete" with serious surgical complications not reported or investigated.
"When reports were made, particularly by junior medical and midwifery staff, there was a concerning lack of investigations made to ensure that women were not being harmed," they wrote.
"The management of complications of O&G surgery was poor, with some consultants failing to 'own' the problem, acknowledge it to the patient and work to try to ensure the best outcome for the patient, with ultimately adverse outcomes for patients.
"Some of these women have suffered likely long-lasting physical and psychological harm."
The review, exclusively revealed by the ABC, was ordered after patient advocate Beryl Crosby approached Mackay Hospital and Health Service's former chief executive Lisa Davies Jones with complaints of patient harm in October last year.
Ms Crosby, who lives in Bundaberg, about 600 kilometres south-east of Mackay, sounded the alarm after she was approached by a frustrated hospital whistleblower.
Affected women then contacted her with serious complaints, including women who required bladder and ureter repairs after they were severed during caesareans or gynaecological surgery at the hospital.
Before the review was ordered, the Mackay Base Hospital lost its accreditation to train doctors in obstetrics and gynaecology.
Two senior doctors were suspended pending the outcome of the review but resigned before it was finished.
The hospital's former director of obstetrics and gynaecology Dr George Campbell Du Toit was banned from practising surgery in June.
Premier Annastacia Palaszczuk said on Thursday she had been advised that the report was "incredibly serious".
"Due to the seriousness of the report, the health minister has asked that she urgently puts this on the cabinet agenda next week, to which I have agreed to. It's that serious," Ms Palaszczuk said.
"Let me assure you, that government will take swift action."
