The Office of the Health Ombudsman (OHO) commenced a systemic investigation following a complaint about maternity services provided to a mother and a newborn baby. The investigation was conducted in the context of a baby's death, and the OHO acknowledges the significant loss experienced by the family.

Wider learnings and recommendations for service improvements

The findings from this investigation highlight broader lessons for enhancing maternity and neonatal care such as:

• Importance of systematic oversight: Robust oversight mechanisms are essential to ensure compliance with safety protocols, particularly in high-risk areas such as neonatal resuscitation.
• Team-based training: Effective teamwork and clear communication are critical during high-pressure situations. Training programs should prioritise these skills to improve outcomes.
• Documentation as a quality foundation: Comprehensive, accurate and timely clinical documentation is fundamental for reconstructing events, ensuring accountability, and driving quality improvement.
• Equipment traceability: Maintaining clear records of equipment checks and functionality is vital for ensuring readiness and compliance with safety standards.

Read the snapshot report (PDF 615KB)