"Wanting answers from the hospital"

About: King Edward Memorial Hospital

(as the patient),

My partner and I have recently gone through and are still going through a horrible ordeal losing our son and having to deal with KEMH – WA’s only referral centre for high-risk, complex pregnancies. I’m writing this as we want answers as to why our son was so damaged at birth, and why the hospital’s policy of “open disclosure” has not, as yet, given us any clear answers - despite his death occurring on the 29th November 2017.

Our son was born on the 26th November 2017 and died 3 days later on the 29th at KEMH. He was 31 weeks, 2 days gestation and was completely healthy, as was the placenta, as was I. I am a high-risk patient, having had 2 pre-term labours previously, at which my first child died shortly after birth (26 weeks gestation). All 3 of my births have required emergency c-sections.

2 weeks after my son’s death, we attended a meeting at the hospital to find out what had happened that night. We were told that the placenta was cut into during a routine c-section and that there was a ‘delayed delivery’. We were told there was a delay by the junior registrar to ask for help and a delay by a senior registrar to provide assistance. We were also told that the Consultant on that night didn’t know a junior registrar was doing the c-section as it was assumed the senior registrar would be. Our son was so bruised and damaged. We left the hospital with no baby, with no discharge papers provided and no medical follow up - 3 nights after I had my c-section.

A Root Cause Analysis of the incident has been conducted, yet we are still waiting for a date to be set for the release of the Report. Originally we were told the process would take 28 days, but it has taken much longer. We have asked for a schedule associated with the release of the report so that we can plan ahead for this and our other commitments over the next period?

The hospital’s handling of its “open disclosure” process has been disappointing and we have been left with many unanswered questions.

As victims of a tragic, yet preventable death, we are struggling to understand who is actually supporting and representing us under the State’s Health Service? We seem to be battling this ordeal alone and feel very isolated from the support and access to health services generally experienced by those living closer to Perth. We will continue to ask and seek answers to our questions for an incident we believe should never had occurred.


Response from Graeme Boardley, Director, Midwifery, Nursing and Patient Support Services, Women and Newborn Health Service, King Edward Memorial Hospital 2 years ago
Graeme Boardley
Director, Midwifery, Nursing and Patient Support Services, Women and Newborn Health Service,
King Edward Memorial Hospital
Submitted on 12/02/2018 at 10:17
Published on Care Opinion at 10:18

picture of Graeme Boardley

Dear Lost

I would like to extend my sincere sympathies to you and your family on the loss of your son. I apologise for the fact that the process of finalising the Root Cause Analysis and Open Disclosure process has taken longer than was anticipated causing you further distress. We are currently arranging for you and your partner to be flown to Perth for the completion of Open Disclosure and are in direct contact with you in relation to those plans.

I further apologise that the care provided to you following your discharge did not meet our expected standard and am sorry that this has added significantly to your isolation and distress. I hope that the Open Disclosure discussion next week will provide the answers you are seeking.

The Hospital’s Perinatal Loss Service remains available to you for support and I encourage you to let me know if you need any further assistance in regards to engaging with the Service’s staff.

Kind regards,

Graeme Boardley

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