Queensland Health Ombudsman report details maternity care failures at Redcliffe Hospital

A whistleblower midwife who alleged dozens of patients had received unsafe maternity care at a Queensland hospital says she has been vindicated by a health watchdog's critical report into the state-run facility.

But Jackie Pulleine is concerned the Health Ombudsman's report, which found nearly a dozen women had received flawed care at Redcliffe Hospital between 2021 and 2022, should have examined more patients over a longer time frame.

"There have been problems there for years. Babies died,'' she said of the 250-bed hospital just north of Brisbane.

The Queensland Health Ombudsman's investigation into Redcliffe maternity services, released last week, found multiple women had received "poor or inadequate" care in the lead up to birthing or just afterwards.

Issues raised included a failure to properly monitor high-risk diabetic patients and medication not being given.

Failing to respond to critical incidents in a timely manner was also raised.

The ABC previously revealed Ms Pulleine had repeatedly tried to report what she alleged was substandard care provided to dozens of expectant mothers at the secondary hospital between 2020 and 2022.

Ms Pulleine alleged her internal reports of the blunders were downgraded or not acted upon and that mistakes were being repeated, putting mothers and babies at risk.

There were stillbirths and neonatal deaths at the hospital involving mothers who allegedly received substandard care.

Frustrated at the lack of action by the hospital, in 2022 Ms Pulleine complained directly to the then health minister.

Her reporting eventually led to the health service ordering an assessment of the hospital's maternity services and notifying the Office of the Health Ombudsman (OHO), which launched its own investigation.

While the OHO investigation was underway in 2023, the hospital told Ms Pulleine her job, which had involved collating perinatal data, had been eliminated.

She alleged this amounted to retribution for her whistleblowing.

The ombudsman's report, which only examined patient treatment between April 2021 and July 2022, detailed how the hospital had failed to properly monitor maternity patients including diabetic mothers who were at high risk of complications.

It said in several instances, concerns about cardiotocography (the monitoring of foetal heartbeat) were not escalated to medical officers in accordance with official clinical guidelines.

In three cases where mothers were diabetics, the hospital was found to have failed to follow official guidelines for blood glucose monitoring, which led to the women becoming acutely ill, the report said.

The report detailed how one mother with Type 1 diabetes and suffering from COVID-19, had presented complaining about her unborn baby's decreased fetal movements.

It revealed a blood test on her admission indicated she was in diabetic ketoacidosis – a condition where her body was suffering from a dangerous build-up of acids called ketones.

The hospital failed to assess her diabetes and record observations like blood sugar levels, the report found.

It found that treatment of the woman's diabetic ketoacidosis was delayed due to staffing deficits in the birth suite and the endocrinologist was not contacted to review the patient prior to delivery.

The baby was delivered by emergency C-section seven hours after the mother was diagnosed with diabetic ketoacidosis and had to be admitted to intensive care for management of respiratory distress and fetal acidosis.

The report revealed a case where a patient did not receive appropriate care including observations and medication because the ward nurse was unaware the patient was supposed to be in her care.

The report identified four instances where the medication of patients was bungled by not being administered in a timely manner or at all.

Clinical records of 10 patients were also found to be incomplete, the report said.

It said the records were "missing vital information relevant to informing patient care or escalation of concerns".

The hospital attributed the failed record keeping to staffing levels, inadequate clinical supervision and potential gaps in staff skills, the report said.

Ms Pulleine said the report vindicated her position, but she was convinced more needed to be done.

'I just feel that finally somebody externally has said yes ok we read the charts, that's right, I was right,'' she said.

"People were saying of me that I should never work in maternity again and that I was mad.

"Talking to staff members who still work there, I'm aware there are still problems with staffing and skill levels."

Ms Pulleine said despite the fact her monitoring of patient records exposed the flawed care and led to major improvements, the department had only offered her a new job sterilising surgical instruments at a hospital some two hours' commute away.

"You can imagine how I feel about that,'' she said.

The ombudsman also investigated Ms Pulleine's allegations that her reporting of bungles was downplayed or not properly investigated.

Ms Pulleine alleged she had been required to speak with management before logging reports of serious clinical incidents in the official reporting system known as RiskMan.

She alleged that her reports had sometimes been downgraded to a less serious rating meaning they attracted less scrutiny.

The ombudsman's report found that sometimes RiskMan reports at the hospital were changed based on the findings of a review or analysis.

It also concluded that the hospital's process for reacting to reports of mistakes or problems needed to be faster and more thorough.

The report recommended the hospital improve methods of providing clinical staff with timely and meaningful feedback from reports of critical incidents.

The hospital admitted that there were times when the logging of critical incidents did not take place in a timely manner – something that was not ideal.

It said the hospital gave assurances that such reports were managed in line with official guidelines.

Meg Flaskett, whose newborn baby died just hours after being born at the hospital last year, welcomed the findings but also raised concerns the report had taken too long.

"Recommendations brought in 2024 are not helping all the babies that died in 2023 or earlier,'' said Ms Flaskett, whose daughter's death at the hospital is the subject of ongoing investigations by the ombudsman and the coroner.

"It should be publicised that a hospital is under investigation."

The health department's Metro North division, which oversees Redcliffe Hospital, said it was implementing the ombudsman's recommendations.

A spokesperson said Metro North could not comment on individual staff movements due to privacy and confidentiality.

The spokesperson said the health service recognised the important role staff and members of the public played in raising concerns.

Redcliffe had supported over 1,330 births this year with a focus on "safe positive birthing experience", the spokesperson said.

The spokesperson said birthing "could be unpredictable and sadly at any hospital on occasion a small number of patients may not have this experience".

She said Metro North had a range of processes in place to support patients or families where there had been an adverse outcome.

A move by Metro North to digitise records meant some manual data entry jobs were no longer needed, and staff had been offered similar alternative duties, the spokesperson said.

In response to Ms Pulleine's concerns about the scope of its investigation, the Office of the Health Ombudsman said it chose to investigate cases occurring between April 2021 and July 2022 because "this was the time period relevant to the complaint".