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

Wider learnings and recommendations for service improvements

The investigation found the antenatal, intrapartum, and delivery care provided was consistent with relevant guidelines and standards.

The investigation highlighted the importance of a trauma informed and person-centred approach towards consumers and identified opportunities for improvement by proposing recommendations relating to:

• Targeted training initiatives with particular focus on providing trauma informed care and bereavement care.
• Strengthening bereavement support with emphasis on improved, timely communication including follow up with grieving families.
• Management of clinical incidents and adverse outcomes, with enhanced open disclosure processes, ensuring proactive engagement with the consumer and their family.

The investigation also identified the importance of services collaborating closely with affected families to develop improved clinical care guidelines that address identified gaps, and highlights the importance of listening to consumers to understand their priorities and perspectives when responding to a consumer’s circumstances.

Read the snapshot report (PDF 121KB)