Midwifery conduct decision: Djerriwarrh Health Services (Bacchus Marsh Hospital)

With thanks to Janine McIlwraith for pointing out what may be the first conduct decision following on from the enquiries on care issues at Djerriwarrh Health Services (Bacchus Marsh Hospital) in Victoria: Nursing and Midwifery Board of Australia v Macrae (Review and Regulation) [2018] VCAT 1707.

The decision about the professional conduct of Ms Macrae related to conduct dating back to 2011 and 2013 in relation to three patients while she was working as a nurse and midwife employed by the Bacchus Marsh Hospital and was the Associate Nurse Unit Manager in the Women’s Unit at the hospital. The three matters concerned neonatal deaths.

Interestingly the alleged conduct included inadequate response to adverse events, in particular Ms Macrae’s failure to respond adequately to a 2011 clinical review of cases attended by her which identified substandard fetal surveillance in each case, and a 2012 fetal surveillance and monitoring assessment which concluded that her knowledge of fetal surveillance was equivalent to a junior ‘supervised practitioner’. The Tribunal noted that she did not undertake formal reflective practice activity to identify gaps in her skills, knowledge or abilities; analyse strengths and limitations in her own skill, knowledge and experience and address those limitations; or focus her CPD activity on the factors drawn to her attention in the clinical reviews of the cases of Patient A and Patient B.

As to the relationship between individual conduct and broader concerns at the hospital, the Tribunal said at [22]-[25]:

We acknowledge that Professor Wallace’s report into perinatal deaths at Bacchus Marsh Hospital made findings about the working conditions for staff at the hospital, including that provision for midwifery education was inadequate and that the lack of out of hours/emergency paediatric cover for neonatal resuscitation and care was a likely contributor to poorer than expected outcomes. Professor Wallace also found that misuse and /or misinterpretation of fetal surveillance by cardiotocography (CTG) was widespread. Mrs Macrae was not the only registered health practitioner involved in the care of patients at the hospital, nor the only health practitioner who worked at the Bacchus Marsh Hospital who has been investigated by their professional Board. Our findings and determinations, however, concern Mrs Macrae’s own professional responsibilities and competence as a nurse and midwife, which are independent of working conditions, and her inadequate response to identified deficiencies in her professional skills despite adverse events.

When asked to view the conduct in the context of the working conditions at the hospital and the systemic failures at all levels, the Tribunal said at [53]-61]:

Counsel on her behalf submitted that while Mrs Macrae does not shirk responsibility for her own failings, including that she was clearly not appropriately skilled in the interpretation of CTGs during the relevant period, she asked that the Tribunal assess her culpability with a number of issues in mind including that her conduct was not borne of laziness or disinterest, rather it was a product of being stretched too thin at her job. Counsel for Mrs Macrae referred to the long working hours, lack of breaks, unexpectedly high and growing patient numbers, old and inadequate CTG machines and no centralised CTG monitoring system, difficulties and delays in obtaining the attendance of doctors including paediatricians.  In short, she submitted, the system that was the Bacchus Marsh Hospital maternity unit at the time, was broken and since knowledge of the infant mortality rate came to light, after the events the subject of this proceeding, major changes and improvements have occurred. Her Counsel described Mrs Macrae as being in “the eye of the storm,” as having no option but to “roll up her sleeves and get on with the job” and that “she did the best she could”.

We recognise that working conditions were difficult and that independent reports found failures at all levels. But, ultimately, a midwife’s professional obligations and responsibilities to the patients in her or his care are paramount. Poor working conditions do not excuse incompetence or dangerous practice.  Patients are entitled to assume that if they come through the doors of a hospital to give birth, they and their babies will receive safe and competent care. And if midwives are unable to safely or competently care for patients because of conditions outside their control and have done all they can to bring the deficiencies to the attention of those responsible, they will need to make their own decision about whether they remain in that workplace. This case illustrates the risks not only to patients but also to professionals who work in such an environment. Dangerous conditions should be reported, documented and publicised.  They should never be normalised, as Mrs Macrae appears to have done. Moreover, Mrs Macrae held the position of ANUM, which had added management and leadership responsibilities and accountabilities. She ought to have demonstrated a higher level of learning and practice.