“There would have been 50 instances or more where they didn’t follow their own policies, and that resulted in the unnecessary death of our son,” she said.
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“They didn’t follow their policies monitoring him during the birth. They failed to escalate to a doctor. They failed to communicate. They failed to document anything … they missed four CTG interpretations.
“The list goes on and on and on. It’s just a catastrophic and cultural failure. None of their policies were followed.
“No one can tell me that this isn’t happening right now in other births in that hospital, you can’t tell me that 20 people didn’t follow their policies in just our birth.”
WA’s Director General of Health, Dr Shirley Bowen, has apologised and admitted the Starkies were failed, but was confident King Edward Memorial Hospital was safe.
“I absolutely regret what’s happened to Alana, and I agree that the policies were not followed for her individual circumstance, but I can assure the public that we do have a safe, quality, high-care system of care at King Edward. I recognise that’s hard given the circumstance we’ve got in front of us,” Bowen said.
A timeline of failures and missed opportunities
For the birth of her fourth child, Alana was referred to King Edward for an induction after her 37-week ultrasound found the possibility of a coarctation of the baby’s aorta. This condition was later ruled out, according to the report.
The SAC1 panel found multiple occasions of staff breaching hospital policy beginning 24 hours before Tommy’s birth, with a lack of an overnight medical review labelled a “missed opportunity” for an abnormal cardiotocography – or CTG – monitor to have been flagged at morning handover.
CTG interpretations should occur half-hourly at a minimum and a “fresh eyes” review by a second practitioner every two hours. The report repeatedly found “this did not occur”.
On another occasion, a CTG interpretation should have been countersigned by a second practitioner. The SAC1 panel was “unable to identify why this did not occur”.
The report notes: “The CTG indicates that the toco was not recording adequately to monitor uterine activity and made interpretation of the trace difficult.”
Eighteen hours after she was admitted, Alana was transferred to the labour birth suite, received oxytocin and underwent a process to induce labour.
However, staff failed to perform a CTG immediately prior, which breached the hospital’s policy.
Once the CTG was up and running staff failed to interpret it every half hour. At one point, two staff reviewed the CTG “collaboratively”, but nothing was documented.
The SAC1 panel found “that both staff may have assumed the other would complete the required documentation”.
Tommy Starkie and his parents, Alana and Paul.Credit: Alana and Paul Starkie
Once the abnormal CTG was identified, the midwife raised it with the registrar face-to-face twice, however “this escalation was not documented nor was a review by the registrar documented,” according the SAC1 finding.
About 90 minutes before Tommy’s birth, a midwife documented abnormal features on the CTG which prompted an escalation to the registrar, who reviewed it remotely. Shortly after the midwife noted “nil concerns voiced”.
The panel found this escalation “did not result in appropriate action as it should have prompted a reduction or cessation of oxytocin which did not occur”, and around that time the registrar was “involved in the management of an instrumental assisted birth”.
Alana’s oxytocin was increased about two hours before Tommy was born, which the panel agreed should not have happened in the context of inadequate CTG monitoring and increasing contractions “with inadequate resting tone”.
And by 8pm – an hour before Tommy was born – the panel found the “CTG demonstrates features highly likely to be associated with fetal hypoxia.” The infant was being deprived of oxygen.
Alana’s oxytocin was reduced upon recognition of hyperstimulation, despite the hospital’s guidelines requiring oxytocin to cease in those circumstances.
From 8.15pm, Alana’s contractions could no longer be tracked adequately.
Following a vaginal examination, a midwife hit the “staff assist” button because of concerns over the baby’s heart rate. A shift coordinator and a second midwife entered the room but failed to act.
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“Neither the primary midwife nor the additional midwives clarified the intent of the staff assist bell, reflecting a lack of shared understanding.” the report found.
Alana experienced immense pain during the final hour of her fourth labour, with the report detailing how she told her medical team she was unable to cope, warning “something’s not right” and that she wanted “to cut the baby out”.
But staff perceived this as “normal” for women during this stage in labour, according to the SAC1 report, and Alana’s description of wanting the baby “cut out” was not perceived as a request for consideration for an emergency caesarean section.
Tommy was born at 9.08pm with poor tone, required intubation and CPR and was transferred to the neonatal intensive care unit. He had a near-total brain injury and died 23 days later. The case is currently before the coroner.
The panel concluded it was unlikely a four-minute period of shoulder dystocia was the primary cause of Tommy’s hypoxia, and that the harm likely occurred throughout labour.
Hospital tech a focus of report’s recommendations
The investigation highlighted potential to improve King Edwards’ primary fetal monitoring system, known as Phillips Intellispace Perinatal, which relies on an algorithm that was “not validated” for use during labour, according to the SAC1 findings. The hospital is adamant the system works safely.
“The panel concluded that the organisation’s fetal monitoring technology is not optimised, and may lack the AI capability of other systems, resulting in a missed opportunity for a technological safety net to have supported the identification of fetal compromise,” the report stated.
Health officials are assessing whether improvements can be made to the software including enhanced AI capability. Staff will also undergo additional education and training to improve CTG interpretations.
The SAC1 report not only finds failures during Tommy’s birth but also with the way his mother was treated in the days that followed.
An ultrasound on September 1, almost 24 hours after Tommy’s traumatic birth, raised the possibility of a uterine tear, which was later confirmed.
No one at King Edward Memorial Hospital ever discussed the finding with Alana.
North Metropolitan Health Service says the ultrasound findings were included in Alana’s digital medical records, however the SAC1 report contradicted that, saying: “No contemporaneous nor subsequent documentation appear in the patient’s DMR about how the ultrasound findings indicated a potential uterine rupture/tear, nor was there documentation outlining that a possible uterine tear/rupture was a differential diagnosis in relation to the patient’s ongoing pain.”
“The omission of documentation does not align with the organisation’s Results Acknowledgement and Communication of Critical Results policy, which articulates the requirement that ‘all clinical decision making and/ or actions arising from the review of electronic test results must be documented in the patient’s medical record’,” the report reads.
“The possibility of its existence was known and therefore should have formed part of the discussion with the patient as part of an effective open disclosure discussion.”
Bowen told 9News Perth this week that Tommy’s birth was a “tragic event”. She said the ultrasound that could have revealed a uterine tear was in Alana’s digital medical record, and an obstetrician was meeting with the Starkies to discuss the situation further.
The report made eight recommendations, including a major cultural reform program aimed at reducing human and technological error, and boosting staffing levels by adjusting ratios for the labour birthing suite.
It also recommended King Edward review the system used to monitor babies as they are being born, with concerns it “may lack the AI capability of other systems, resulting in a missed opportunity for a technological safety net”.
A major review of the labour birthing suite’s emergency response processes, a new clinical documentation policy, and an overhaul of the open disclosure of serious adverse events at the hospital formed the remainder of the review’s recommendations.
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North Metropolitan Health Service chief executive Robert Toms has also apologised to the Starkie family.
“The review identified eight contributing system factors and eight recommendations have been identified to improve these systems to ensure such incidents don’t happen again,” he said.
“All of those involved are deeply impacted. They go to work each day wanting to provide the best possible care.”
Alana welcomed the report’s recommendations – “if they’re implemented”.
“If they’re implemented, I do think the recommendations are good, and I do think it will make it safer, but I’ll say this: how do you fix a broken culture, a culture that is broken so badly that this SAC report is showing?”
“Our primary focus is making sure this disaster never happens again, that another baby doesn’t have to suffer like our Tommy did in his 23 days and no family has to go through the trauma and distress of holding your baby son while he dies in your arms, no parent should have to go through that and no parent should have to go through that because of a fundamental failure of the medical system,” she said.
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