How a crisis at one maternity service became a catalyst for change across the Victorian public hospital system: A discussion paper

Background In Victoria, Australia, public hospitals are administered through a system of devolved governance. Overall, Victoria's public health system has a record of good performance when comparing measurable safety outcomes to the rest of Australia. However, in 2015 a cluster of preventable perinatal deaths were identified at a health service in Melbourne's outer fringes. Questions What were the factors that contributed to these preventable deaths, and what were the outcomes of the four key inquiries commissioned by the Victorian government after the identification of the cluster? What can be learnt by comparing this crisis in one Victorian health service to similar events at other health services in Australia and the United Kingdom? Methods This paper discusses the crisis at the Victorian health service and expands on the factors that contributed to the crisis, the inquiries, subsequent recommendations, and the response from the Victorian state government. Similarities between this case and others in Australia and the United Kingdom are discussed. Findings A common theme in the four inquiries into the crisis at the health service in Victoria was that inadequate clinical governance was a key factor that led to these events. As a result, a number of significant changes were implemented across the state to improve patient safety across all areas of health care. When comparing this Victorian crisis to similar events at other health services across the world, inadequate clinical governance consistently appears as a key contributing factor to poor clinical outcomes. Discussion All cases discussed had a delay in the identification of clusters of poor clinical outcomes. This was found to be a direct result of inadequate clinical governance structures at both a local and government level. Conclusion A robust clinical governance framework that is enacted at both the government and the health organisation level is essential to deliver high quality and safe patient care.