On 21 December 2015, the Queensland Office of the Health
Ombudsman ("OHO") issued its investigation report into
the quality and safety of maternity services at Beaudesert
Hospital, part of the Metro South Hospital and Health Service
The Beaudesert Hospital is a rural health facility which
provides low-risk birthing and procedural services, categorised as
a Level 3 within the Clinical Services Capability Framework
("CSCF"), which means that the facility can provide low
to moderate complex inpatient and ambulatory care services.
In July 2014, the OHO and MSHHS both received a complaint from a
member of staff at the hospital regarding the clinical
communication and managerial skills of a medical practitioner. The
OHO commenced its investigation into the allegations against the
medical practitioner, while the MSHHS commissioned an independent
clinical review of maternity services at the hospital.
Independent Clinical Review
In December 2014, the MSHHS produced the findings of the
independent review to the OHO. The reviewers made recommendations
including that Queensland state-wide Maternity and Neonatal
Clinical Guidelines are used to guide the care of patients,
and that those guidelines be incorporated into local procedures or
The reviewers also recommended that consideration be given to a
review of antenatal care for women who are not suitable to deliver
at the hospital, and there be improved communication and
documentation between the hospital and the alternative care
Finally, the reviewers noted that the overarching clinical
governance was being reviewed and that changes had been implanted
including "robust guidelines for the acceptance of
obstetric patients and weekly clinical review meetings attended by
a consultant obstetrician".
On 30 March 2015, the OHO issued MSHHS with a notice pursuant to
section 228 of the Health Ombudsman Act 2013 requiring
How the recommendations of the Independent Clinical Review were
distributed to staff;
What action had been taken since the findings of the Review
The outcomes as a result of the actions taken; and
The future actions established as a result of any
The MSHHS provided the OHO with the details of the actions
taken, including a comprehensive plan which included 21 individual
recommended actions with associated timeframes for implementation.
All 21 actions had been implemented, and most were subject to
ongoing monitoring requirements.
Following consideration, the OHO was of the view that there were
no deficiencies in the recommendations, nor any issue with their
implementation, and that the MSHHS had taken appropriate action to
improve the clinical services within the Beaudesert Hospital
maternity unit. The MSHHS had addressed any issues by implementing
initiatives and improvements to the local work instructions. Any
risk to public health and safety had also been appropriately
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