In a report published today, Queensland’s Acting Health Ombudsman noted that Gold Coast University Hospital’s (GCUH) maternity service meets standards for safe quality care, however an investigation examined whether there were issues with the hospital’s response to previous adverse maternity events.

Acting Health Ombudsman Andrew Brown said that “learnings that are applied and actions taken by a hospital in response to adverse events are critical to reducing the risk of them occurring again”.

“Our investigation was part of my office’s commitment to protecting the health and safety of the Queensland public and was prompted by a number of adverse events that had occurred since the hospital’s opening in 2013,” Mr Brown said.

“A number of families experienced painful and tragic outcomes while receiving care in the GCUH maternity service. While the number of these adverse events is small, any one of this type of adverse outcome has immense impact on the parents, children and families, as well as the health practitioners delivering the care,” he said.

During the Health Ombudsman’s investigation it became clear that the systemic issues identified related not to the quality of the maternity service provided at GCUH, but to the Gold Coast Hospital and Health Service’s (GCHHS) response to these events.

The Office of the Health Ombudsman’s (OHO) published report details the findings that GCHHS had an overly complex safety and quality governance structure; deficiencies in recording and monitoring of recommendations implementation; and GCUH lacked sufficient systems to consistently manage obstetric patients presenting to other departments.

“Our own review was extended as new complaints were received about adverse events reoccurring after the investigation began in December 2014,” Mr Brown said.

“The additional complaints and information enabled the office to understand and distil the underlying systems issues.”

The Health Ombudsman’s report makes eight recommendations to address the key issues, targeted at improving GCHHS’s accountability, transparency, and safety and quality governance to prevent adverse outcomes reoccurring insofar as is practicable.

GCHHS has accepted all recommendations in the report.

“Overall, I am satisfied GCHHS provides a safe and quality maternity service and one committed to continuous improvement and patient safety,” Mr Brown said.

“GCHHS has already worked extensively to address the issues my office has identified; much of this work was undertaken independently and proactively, parallel to the OHO investigation.”

“GCUH is now rightly focused on further revising and refining its clinical incident management framework—where there is the most room for continuous improvement.”

“This office intends to monitor the recommendations through a collaborative approach with GCHHS, which will enable the Office of the Health Ombudsman to be more responsive to the changing nature of the health environment while still retaining an oversight role to ensure that the recommendations are fully and effectively implemented.”

The full investigation report is available to download from the OHO website at www.oho.qld.gov.au.

—ENDS

Media enquiries:

media@oho.qld.gov.au 0427 483 656