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Legislative Assembly for the ACT: 2005 Week 13 Hansard (Wednesday, 16 November 2005) . . Page.. 4227 ..


outset, I would like to say that the commissioner’s investigation concludes that there was no issue of public safety in the obstetric service at the Canberra Hospital. Nor did the evidence obtained in the investigation indicate an unacceptable level of avoidable adverse patient outcomes.

The commissioner has also concluded through his investigation that, while the evidence obtained in the investigation indicated issues of concern in the management of some cases, there was no issue of public safety in the practice of individual clinicians. The commissioner further concluded that the evidence obtained in the investigation identified some aspects of the obstetric service that could be improved.

Let me give members some more detail. The review of obstetric services at the Canberra Hospital was an own initiative investigation by the Community and Health Services Complaints Commissioner. It was undertaken in response to a letter written on 29 September 2003 by the chairman of ACT state committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists to the ACT Medical Board, expressing concern about the pattern of obstetric care at the Canberra Hospital and identifying one particular case with an adverse outcome.

The medical board decided to refer the matter to the Community and Health Services Complaints Commissioner. On 3 December 2003 the commissioner notified ACT Health of an investigation into obstetric services at the Canberra Hospital, the purpose of which was to determine whether the complainant’s allegations were justified. The commissioner decided that an expert and peer opinion on the standard of care delivered in the cases of adverse outcomes brought forward by the ACT state committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists would be an appropriate measure of the safety of the obstetrics service.

The commissioner appointed two experts—who, under the Community and Health Services Complaints Act 1993, cannot be identified—to undertake a review and requested that they provide an opinion on the performance of the Canberra Hospital’s obstetrics services against the performance indicators of the Australian Council on Healthcare Standards and the Women’s Hospitals Australasia benchmarks. The two experts reviewed all the material provided by the ACT state committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the clinical data for the obstetric service itself and the clinical records and statements provided by practitioners involved in the care given in the individual cases under review. Their review covered the period 1994 to 2003.

Overall results for perinatal mortality and morbidity during that period do not indicate a problem with the care provided by the Canberra Hospital obstetrics unit. It is reassuring for the Canberra community that the Canberra Hospital obstetrics unit’s performance against the Australian Council on Healthcare Standards’ indicators and Women’s Hospitals Australasia benchmarks showed that there was no significant deviation from the overall pattern seen in other similar institutions. The report makes six recommendations, four of which were related to improving the obstetric service at the Canberra Hospital. Recommendation 1 states:

The Canberra Hospital Obstetrics Unit develop and implement an assessment protocol for ongoing assessment and performance concerning APGAR scores.


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