A consultant at a Victorian hospital where a number of babies died raised the alarm about an extreme risk to its obstetric service, then failed to follow up, a tribunal has found.
In 2016, a scathing review found 11 babies died in potentially avoidable deaths at Djerriwarrh Health Service at Bacchus Marsh between 2001 and 2014.
Their deaths triggered a massive overhaul of the state's health system, including radical reforms to the health service.
Dr Lee Gruner was a consultant director of medical services with Djerriwarrh from 2009 to 2015.
The Medical Board of Australia alleged she continued in the role when she ought to have known she couldn't live up to its requirements.
The board also alleged Dr Gruner stayed in the position without a clear outline of her professional obligations and duties and there were deficiencies in her performance to ensure the safe delivery of clinical services.
Dr Gruner denied all the allegations except one, admitting in 2010 she reviewed medical staffing in the obstetrics department given the number of births was increasing.
In a report, she concluded the obstetric service was at extreme risk as a result of rapidly increasing clinical workloads, an unsustainable medical model which provided inadequate leave cover.
She warned there would be an extreme risk to future service delivery and safety if the appropriate changes weren't made.
Dr Gruner reiterated her concerns to the chief executive and the health service took action in the wake of the report, employing a second obstetrician and joining the Hospitals in the West program, which aims to strengthen coordination across hospital services.
However, she failed to follow up about whether the health service addressed the risks - a decision the Victorian Civil and Administrative Tribunal found was a critical failure.
The tribunal also found the rest of the allegations against Dr Gruner proven, despite her contention her role did not include any of the ordinary responsibilities of a medical director and carried with it no responsibility to ensure the safe delivery of services.
The tribunal rejected that claim, in part because there was no other person employed as a director of medical services at Djerriwarrh, and she was engaged on an ongoing rather than short-term basis.
Dr Gruner started her role working 10 days onsite and 10 days offsite in 2009, but later in her term that dwindled to a couple of days and being available for advice when needed.
"Her case was to the effect that she was in every respect a consultant but in no respect a medical director," tribunal members said in their decision.
"The board's case is that her title is more plausibly read as giving meaning to all of its words."
The tribunal is yet to determine whether Dr Gruner's actions amount to professional misconduct or otherwise, or to decide whether she should be reprimanded.
Western Health declined to comment on the matters raised.
"As Dr Lee Gruner was not an employee of Western Health, it would be inappropriate to comment on the recent findings by the Victorian Civil and Administrative Tribunal," a spokesperson said.
