Kwinana Freeway: St John of God Midland Public Hospital release SAC1 report to couple after roadside birth

A hospital investigation has called for all birthing mothers to receive ambulance transfers and an additional examination in a maternity bypass scenario after a heavily pregnant Perth mum was forced to give birth in the back of her car on the Kwinana Freeway. St John of God Midland Public Hospital has released their Severity Assessment Code 1 (SAC1) report to the young couple after their traumatic experience on November 13 last year. SAC1 cases are clinical incidents that caused or nearly caused serious harm or death. The damning investigation outlines how staff only advised the pregnant mother, Lena, of the fact they were in maternity bypass — when a pregnant woman needs to be transferred to another hospital because no beds are available — after making her wait several hours for a bed that didn’t exist. Lena and her partner, Abdul, were advised to go to Rockingham General Hospital — about an hour’s drive away. Hospital staff also didn’t conduct a vaginal examination a second time before allowing Lena to go — despite her contractions worsening — and letting her crawl into the back of her family’s Toyota Kluger instead of organising an ambulance transfer. It was inside that car Lena gave birth to baby Sofia on the side of the freeway in Atwell, just 20 minutes into their drive. A harrowing phone call, made by Abdul from the emergency lane, revealed the moment the couple thought their baby was dead after Lena managed to give birth in the back seat. A shocked Lena looked across and braced herself for bad news as she saw Abdul on the phone to triple-0 screaming out: “Hey, hey, hey, it’s not breathing. I need help. I need help. The cord is wrapped around (it‘s neck).” Acting on instinct, the couple managed to untie the umbilical cord, but as Lena grasped her fragile baby girl close to her chest, she thought the worst. Thankfully, Sofia miraculously survived. After The West Australian revealed the couple’s harrowing story, the hospital informed Lena and Abdul that the report had been completed. A copy of the SAC1 clinical incident investigation, signed off by the hospital earlier this month and later reviewed by the Health Department, was released to the family on Thursday, revealing how the hospital is now reviewing policies about the treatment of birthing mothers in a bypass situation. As detailed in the report, there is currently no policy requiring maternity ward staff to perform a vaginal examination immediately prior to transferring a patient from hospitals during a bypass scenario. This leaves staff unable to effectively determine how close a mother is from giving birth before they are handballed to another hospital. In Lena’s instance, the hospital still admits staff should have conducted an examination despite there being no policy requirement. And in a damning recommendation, the review says women receiving labour care in a bypass situation must be transferred by ambulance instead of a getting them to travel in their own vehicle. Lena and Abdul previously said they were denied an ambulance by Midland staff. Why staff picked Rockingham Hospital, considering there are closer options, is not detailed in the report. It did state there was an “absence of documentation from the registrar, within the medical record, outlining the handover discussion and the acceptance of the patient (between Midland and Rockingham hospitals)“. The West Australian has seen the medical record, which also shows a lack of detail regarding the clinical decision-making. The report revealed that the bypass directive made at SJOG Midland was called at 5.30am on November 13, a decision that was supported by the investigating panel. The reasons behind the decision to call maternity bypass was put down to staff calling in sick, the inability to find replacements and beds being full. Lena arrived at the hospital at 3.35am that morning with her first, and only, examination occurring at 4.10am. She then moved to the waiting room at 5.10am. Just 20 minutes later the maternity ward got so full that a bypass directive had to be issued. But Lena wasn’t made aware until more than two hours later, just before she was told to crawl into her own car. That same bypass directive at the SJOG Midland lasted 11 hours according to the report. At least two other mothers were transferred for ongoing care the same morning. The SAC1 report called for maternity bypass transfers to be approved by clinical midwife managers and obstetric registrars prior to a decision being made. There is currently no policy requiring this, raising concerns about the effectiveness of clinical decision-making, as was the case with SJOG Midland picking Rockingham. The Health Department previously said no other hospitals in the metropolitan area were on bypass at the time staff decided on Rockingham. Health Minister Meredith Hammat said she expected all recommendations from the review to be implemented. “I want to thank Lena and Abdul for taking part in this clinical review, which has helped to ensure our health system learns from their experience and works to prevent similar errors occurring again,” she said. “The State Health Operations Centre is now overseeing and managing demand of our public maternity services. “We are committed to rolling out nurse and midwife-to-patient ratios across our health system to strengthen patient safety and support nurses and midwives, with the most recent phase of the rollout starting earlier this week.” The hospital is due to provide a progress report about the effectiveness of the implemented recommendations to the Government within six months. The suite of changes are to be evaluated by the WA Health Patient Safety Surveillance Unit before being implemented. Any improvements to the system at a local level could then be implemented across the system. Community advocate Suresh Rajan joined the couple this week to meet with hospital executives as they delivered the report. Mr Rajan, representing the family, said he suspected other hospitals were hesitant to accept Lena over the phone because they were overworked and were anticipating other arrivals. “The hospital said the reason they have the conversation over the phone is because you need to have an appropriate midwife-to -midwife conversation to assess the capacity of the person to travel . . . but the midwife never assessed the capacity by way of vaginal examination,” he said. “Why was it necessary for the the midwife to be talking about the capacity of the girl to travel when she herself had not assessed that?” Mr Rajan called on the Health Minister to implement the changes urgently. “Had there been any complications, the back of a car would have been the most inappropriate place for the child to have been born,” he said. “It’s unfortunate that we’re in a state of play with our hospital system that it’s going to take media stories before we get action in relation to potential negligence or potential problems that may have occurred in the hospital system. “ St John of God Midland Hospital is operated under a public-private agreement between the State Government and St John of God Healthcare.