26 October 2007

Inquiry into miscarriage at Royal North Shore Hospital

The NSW Government today received the report of the inquiry into the care of a patient with threatened miscarriage at Royal North Shore Hospital.

The Minister for Health, Reba Meagher, set up the inquiry, after Jana Horska miscarried in the Emergency Department at Royal North Shore Hospital on September 25.

The inquiry was conducted by Professor William Walters AM, Executive Clinical Director of the Royal Hospital for Women Randwick, and Professor Cliff Hughes AO, Chief Executive Officer of the Clinical Excellence Commission.

The Report found:

• Ms Horska had to wait too long in the waiting room and that she was denied the dignity to which she was entitled when the miscarriage occurred;
• That staff working in the Emergency Department on the night of September 25 acted appropriately within existing protocols and none would be referred to the Health Care Complaints Commission by the inquiry team;
• There was an absence of specific protocols for women presenting with a threatened miscarriage, who should be assessed as a matter of priority;
• New models of care should be developed as a matter of urgency for all public hospitals concerning the management, care and treatment of patients presenting with miscarriages or threatened miscarriages;
• It is important that appropriate emotional support be provided to women who present with miscarriage or threatened miscarriage in an Emergency Department setting;
• There should be a public education program targeting people who present to Emergency Departments with relatively minor conditions that could be better managed by a GP clinic or other primary care facility.

The Report also made a number of recommendations specific to Royal North Shore Hospital, including that it review its policies relating to security and the physical environment of its Emergency Department.

A number of other recommendations have been made in relation to statewide guidelines to ensure uniformity of emergency department signage, development of fact sheets and other communication for patients who present to emergency departments with a threatened miscarriage or for staff who deal with those patients.

A key recommendation was that Governments explore opportunities to provide information on early pregnancy, including miscarriage, with pregnancy testing kits sold at pharmacies. This would require the assistance of the Therapeutic Goods Administration (TGA).

"I would like to thank Professor Hughes and Professor Walters for their invaluable assistance in compiling this report so as to ensure significant changes in the way early pregnancy complications are dealt with in NSW public hospitals," Ms Meagher said.

"I have asked NSW Health to develop an implementation plan for the recommendations and expect to be able to report back to the NSW Parliament within a month with a detailed response to the report."

For a range of health information, go online to www.health.nsw.gov.au