A Western Sydney maternity ward was significantly understaffed and vulnerable to overnight medical emergencies when several infants were stillborn or died shortly after birth, documents obtained by the ABC have revealed.
Jennifer Fonua found special significance in the fact that her sixth child, whom she planned to call Thalia, would be born at the same hospital as her five older siblings.
So when she was admitted to Blacktown Hospital in April 2019, she said was comfortable and at ease with the staff.
"The midwives and the nurses there, they cared for me. When I went for my baby check-ups, they were always there for me, they knew me," she recalled.
Ms Fonua had been admitted three days ahead of a planned caesarean.
She said she was feeling well and was looking forward to meeting Thalia, but had noticed the baby hadn't been moving as much over the previous few days.
They started monitoring the baby's heartbeat, and just before midnight doctors decided she need an emergency caesarean within an hour.
The heartbeat monitor, called a CTG, was removed when Ms Fonua was taken to get ready for theatre, but then she waited more than two hours after another urgent case was given priority.
"I was a little bit concerned because I knew at this point my daughter's heartbeat was dropping, but I trusted them to do right by me," she said.
"They did say they were going to put me back on the machine to monitor her heart, so I was OK with that.
"However, once they went to check her heart, that's when they didn't find her heart [beating]."
Around 3:30am, Thalia's death was confirmed.
"It was one of the hardest things to hear, because for me it was a few minutes ago I heard her heartbeat, like a bunch of horses racing … the galloping," Ms Fonua said.
"And then I remember crying and saying, 'Bring me my partner. I need my partner. I need him here right now.'
"They put me into theatre. I remember it was so silent, no one was speaking … and you knew that it wasn't right."
She was delivered stillborn an hour later.
An investigation into Thalia's death, called a root cause analysis, found the CTG shouldn't have been removed, and the medical team didn't fully appreciate the baby's worsening condition.
"The insufficient CTG monitoring resulted in a missed opportunity to detect deteriorating fetal condition and expedite delivery," the investigation found.
Four deaths prompt district-wide review
By the time an internal review into the Western Sydney Local Health District's (WSLHD) maternity services was commissioned in mid-2020, a total of four babies had died unexpectedly in the space of 18 months, including Thalia Fonua.
That review, which was obtained by Greens MLC Cate Faehrman through the NSW Parliament, found Blacktown Hospital was understaffed and the overnight roster included no senior medical staff, leaving it exposed to emergencies overnight.
"The midwifery workforce has significant deficits with ongoing vacancies … the recruited workforces is relatively junior and inexperienced," the review stated.
"The overall senior medical staffing of the service at Blacktown is suboptimal … the medical workforce appears to be organised around individual clinicians rather than organised for safety."
General secretary of the NSW Nurses and Midwives Union Brett Holmes said midwives were working under enormous pressure.
"That leaves an enormous burden on that midwife because they're looking after up to 12 mothers … and 12 babies.
"There still is a very heavy reliance on junior midwifery staff.
"They're developing their skills, but until you have sufficient numbers of midwives there and not rely so much on registered nurses to backfill the midwives, those midwives won't be able to continue to develop the full range of skills that that would be normally expected of them."
In a statement, a spokesperson for the WSLHD said they had hired 19 midwives, a birthing suite midwifery unit manager, and a clinical nurse educator to support after hours.
The statement said five nurses are being upskilled in midwifery, and seven more nurses were filling in while recruitment for the rest of the promised 28 midwives continued.
An additional night shift registrar has also been added to the roster.
NSW Health Minister Brad Hazzard said in a statement he was pleased with the progress made by the hospital so far.
"I instructed NSW Health to ensure more midwives were employed and changes made in the medical staff to ensure that structures and processes were in place to address the issues raised in the Resilience Review," he said.
"I am pleased to see progress on that front with the recruitment of an additional 19 midwives and other staff in key positions that are a major boost for the hospital's maternity service."
Midwives struggling under workloads
In late 2020, midwives walked off the job and 20 obstetricians threatened to resign in response to their ongoing concerns about lack of staff and resources.
At the time, the WSLHD was already in possession of the internal review which echoed many of the issues raised by workers, including the understaffing of the maternity ward.
Another two babies died in unexpected circumstances in the months following.
The review also found that clinical midwives struggled to attend morbidity and mortality meetings — where incidents like Thalia Fonua's death might be reviewed — because of their workload.
It stated a long list of recommendations formed in direct response to root cause analysis investigations, like the one undertaken into Thalia Fonua's death, still haven't been actioned.
A WSLHD spokesperson said safety huddles and clinical handovers had been established in all maternity wards to address safety concerns, as part of the response to the review.
"WSLHD follows a rigorous process to ensure we identify, investigate and learn from any incidents that occur in our hospitals," the spokesperson said.
"All unexpected deaths in our hospitals are thoroughly investigated with a Root Cause Analysis which, if required, comes with recommendations for implementation.
"A review of all local obstetrics and gynaecology policies and procedures has been completed in WSLHD."
Medical negligence barrister and registered nurse Ngaire Watson said the internal review showed a lack of accountability and ability to learn from mistakes.
"The report indicates that there have been root cause analyses conducted after serious incidents, but the findings from these are not being fed back into the system so that they can change what's happening within the system — so the problems keep getting repeated," she said.
"I think it would be very distressing for midwives not to be able to participate and feedback into a system when they are the ones ... who actually know what's happening at a patient care level.
"They're in a very difficult situation where they're trying to provide care in an environment where it's very difficult to do that, and within a system that's not really listening to what they're saying."
A WSLHD spokesperson said all 18 recommendations made in the internal review have been accepted by the district, with 12 completed and the remaining six expected to be finalised early this year.
Almost three years on, Jennifer Fonua is frustrated that there are still unresolved issues at Blacktown Hospital, and that other families have had to experience what she has.
"[Thalia] would be three in April. I'm still waiting for things to be changed," she said.
"I've seen since my daughter's death in April 2019 [that] nothing has changed, more babies' deaths have arisen.
"I now live with mental illness, I live with depression, I live with anxiety.
"But I push myself every day because they need their mum. My children need their mum."
Watch this story on 7.30 tonight on ABC TV and ABC iview
