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The Hon. IAN WEST: My question is addressed to Minister for Health. Will the Minister advise the House on the progress of the investigation at Blacktown Hospital?
The Hon. JOHN HATZISTERGOS: I am sure that all honourable members shared my shock and sadness upon hearing about baby Angelina, the stillborn baby whose body disappeared from the Blacktown Hospital mortuary. This was a tragedy, and I again express my deepest sympathies to her family. Honourable members will be aware that there have been a number of investigations into this issue. Two of these—a police investigation and a preliminary report by the area health service—have been completed. In addition, I have referred the matter to the Health Care Complaints Commission for investigation.
Today I can advise the House that the independent inquiry being conducted by Professor Caroline Homer has been completed and the report has been provided to me this morning. I understand that Professor Homer requested, and was granted, a 24-hour extension to complete the report. The chief executive officer of Sydney West Area Health Service is meeting with the family to discuss the inquiry's findings. I am advised that today was the earliest time that all relevant staff and Professor Homer were available for a meeting. As honourable members will understand, the report contains private medical information. Therefore, while a copy of the full report will be provided to the family, the report will not be made public without their permission. While I cannot comment on the detail of the report, I can report to the House on its conclusions and recommendations. The inquiry found:
… there is no evidence of a cover up by the Administration of Blacktown Hospital.
The inquiry concluded:
… on the balance of probabilities, baby Angelina was inadvertently removed from the mortuary with clinical material on 17th May 2006.
The report identifies a number of factors that may have contributed to this outcome. The inquiry further concluded:
… this incident is the result of an unfortunate sequence of events, and although procedures were followed, they were inadequate to prevent this occurrence.
The report went on to state:
… with the benefits of hindsight there are clear weaknesses in existing procedures.
Finally, the report concluded:
… there is no evidence of gross negligence on the part of any individual …
The report has not recommended disciplinary action against any individual. The report makes a number of detailed recommendations to improve current procedures and to prevent any repeat of this tragic incident. These recommendations include: improvements in the identification of stillborn babies and foetuses under 20 weeks, changes to mortuary storage and security procedures, clearer policies regarding the removal of clinical material from the mortuary, training for staff on new policies and procedures, and the development of systems for regular monitoring and audit.
The inquiry further recommends that there should be a review across Sydney West Area Health Service to ensure that the recommendations of the inquiry are implemented and that standardised policies and procedures are in place. Finally, the report recognises it is likely that some of these issues will apply in other area health services and therefore the recommendations should be provided to NSW Health for consideration as part of the broader statewide review of existing policies to ensure that best practice standards are being met. I can advise the House that I will be asking the area health service to implement all the inquiry's recommendations.
The investigation report will be provided to the Health Care Complaints Commission. The findings of the report will also be provided to the New South Wales Maternal and Perinatal Committee, which is overseeing the statewide review of the management and guidelines for the management of stillbirths. I again express my sincere sympathies to the family regarding this tragic event. I also stress again the importance of respecting the wishes of families in such circumstances.