A doctor has been barred from practising medicine for 10 years for professional misconduct during a cluster of potentially preventable stillbirths and newborn baby deaths at a Victorian hospital.
The Victorian Civil and Administrative Tribunal (Vcat) found Dr Lee Gruner failed to ensure the safe delivery of clinical services at Bacchus Marsh hospital between 2009 and 2015, during which time a number of babies were stillborn or died. The hospital was operated by Djerriwarrh Health Service at the time and Gruner was the hospital’s consultant medical services director.
Evidence submitted by the Medical Board of Australia (MBA) to Vcat said the health service relied on Gruner’s expertise and guidance in relation to clinical governance.
“That reliance was misplaced,” the board submitted. “There were considerable failures of clinical governance at Djerriwarrh Health Service during her tenure, in particular in relation to the obstetrics unit.”
Vcat found three allegations of professional misconduct against Gruner to be proven, including that she continued in the role despite knowing she could not fulfil the requirements to ensure safe care.
Gruner did not undertake appropriate performance reviews of medical officers or ensure they were appropriately credentialed and working within their professional limits, Vcat found. She also failed to address identified risks of inadequate medical staffing in the obstetrics unit, the tribunal found.
“As a low-risk birthing facility, the number of adverse outcomes over [a] short period of time should have led to ‘alarm bells ringing’ but did not,” said the tribunal’s decision, published on Monday.
Little action was taken to identify the causes of the adverse outcomes or implement changes in practice, the tribunal found.
An independent investigation into the obstetrics unit, ordered by the Victorian government, found the deaths of seven babies between 2013 and 2014 could have been avoided.
It found Djerriwarrh Health Service failed to update its practices around obstetric and midwifery care, leading to a series of catastrophic clinical and governance failures that may have contributed to the deaths.
The tribunal heard that despite Gruner writing a report to the Djerriwarrh Health Service in 2010 warning that the obstetric service was “under extreme risk as a result of rapidly increasing clinical workload” and that “immediate action needs to be taken to address the short-term issues so as to ensure a safe and quality service”, she never followed up to ensure action was taken.
Gruner did not contest the allegations that she failed to follow up on the report.
Vcat ordered that Gruner’s registration be cancelled and she be banned from reapplying for 10 years.
Gruner, 74, has already retried from clinical practice. But the tribunal found disciplinary action was still needed to deter similar behaviour from others in positions of power.
“Furthermore … Dr Gruner demonstrated a troubling lack of insight into her own conduct and into professional standards more generally,” the decision said. “Her evidence before the tribunal was ‘confused’, ‘convoluted’, ‘unpersuasive’ and ‘self-serving’.”
Dr Anne Tonkin, the chair of MBA, said there was “no excuse for those in clinical leadership roles not knowing what is expected of them”.
“We should not need to go through these tragedies to learn these lessons.”
The Australian Health Practitioner Regulation Agency (Ahpra) and the MBA first began investigating the cluster of deaths in 2015, launching investigations in relation to 101 matters about the care provided. Concerns were raised about 43 registered health practitioners, with some practitioners the subject of multiple incidents.
Ahpra’s CEO, Martin Fletcher, said: “Our hearts go out to those families who lost babies.
“It is vital that lessons are learned to improve patient safety to prevent future harm for other families.”