Speaker 1:

These are among the impressions left by tiny Jack [Batton], born Perth, March 15, 2000, died March 16, 2000.

Speaker 2:

Merry Christmas! Ho, ho!

Speaker 1:

Nine months after Jack's death, Christmas festivities swept the City of Perth, as usual. But 50 kilometres away, Christmas was a more sombre affair.

Dean:

See if I can get in down there.

Speaker 1:

It was a Christmas Jack's parents, Dean and Sadie, expected to share with him, and without him, they chose to spend it alone, away from family and friends.

Dean:

And this is a special Christmas present.

Speaker 1:

Dean's present to Sadie is a holiday for the pair of them, with the idea of being anywhere but here on the approaching anniversary of their son's death.

Dean:

This is gonna be the hardest time on his first birthday, so I thought we'll go to a place we've never been before.

Speaker 1:

Jack only lived a couple of hours, but left a lasting impact on the lives of his parents.

Dean:

I love you.

Speaker 1:

They believe his death at one of the most respected hospitals in the country could have been avoided.

Dean:

At least you've got somewhere to go.

Speaker 1:

A death that holds hard lessons for public hospitals right around the country.

Sadie:

Thank you.

Dean:

I believe in the right setting and with the right experience, there's no reason that we shouldn't be sitting here celebrating with our son.

Speaker 1:

Tonight on Four Corners, the lost and damaged lives hospitals call adverse outcomes. Jack Batton was born premature at King Edward Memorial hospital at 25 weeks and four days. If he had survived, he'd have joined the other babies here in the neonatal ward. Just a decade ago, it was a battle to save babies born at 26 or 27 weeks. Now it's commonplace at King Edward to save babies at 24 or 25 weeks, some even more premature.

Speaker 5:

Christian was born at 23 weeks and two days, and wasn't due so that makes him due the 10th of March. So hopefully, he wasn't home for Christmas, but hopefully he'll be home for Easter.

Speaker 1:

The neonatal ward has an extraordinary survival rate of up to 90% for babies like Jack. But by the time Jack Batton got here, it was already too late. Severely bruised, his leg broken, his lungs had been starved of oxygen during delivery.

Speaker 6:

Okay, here we go in and ...

Speaker 1:

King Edward is the only specialised maternity hospital in WA, taking almost every high-risk birth in the state.

Speaker 6:

Hello. How are you?

Speaker 7:

Good, thank you.

Speaker 6:

Enjoying your little rest?

Speaker 7:

Yeah, yeah, yup.

Speaker 6:

Okay.

Speaker 1:

It's also WA's only teaching maternity hospital.

Speaker 6:

There we go. Tell me what you think.

Speaker 1:

In this instance, these junior doctors are presented with a full-term patient with complications. And the discussion, as always, is about if, and when to intervene.

Speaker 6:

So the last baby was three, four weeks. Five. [crosstalk]. So I guess it's a balance, isn't it, between not wanting to intervene, her desire for us not to intervene, which is perfectly reasonable, the knowledge that if we don't intervene, her chances of delivering normally are better, and once we start intervening, then we get what we call this cascade of intervention. One intervention leads to another. If we induce her ... [crosstalk]

Speaker 1:

But King Edward is also a hospital and a strain. Once, doctors would vie for a full-time position here. Now, few doctors want the job, preferring less risky and more lucrative private practise with just a few consulting sessions a week at the hospital, says the doctors' spokesman, Dr. Tim [Pagey].

Tim P.:

This is a dangerous hospital to practise in because of the nature of the women that we deliver. Often they often very sick with very small premature babies, and the outcomes are liable to be bad. We have a much higher risk population all around. And, people seek to blame somebody if their baby's less than perfect. And, understandably, an awful lot of obstetricians who would otherwise have given their services have just said, "It's not worth it."

Speaker 6:

Well, that sounds nice and healthy.

Speaker 1:

The result [crosstalk], more and more of the burden has shifted to junior doctors still in training.

Speaker 6:

So now we've got to decide what to do. What would you do?

Speaker 1:

Registrars with as little as a few months [crosstalk] experience. Time and time again, [crosstalk], they were confronting the most difficult cases of all on long shifts, often after-hours, unsupervised.

Speaker 6:

All right.

Speaker 9:

Okay. [crosstalk].

Speaker 6:

Thank you very much. See you.

Speaker 9:

Thanks, you too.

Tim P.:

It's not surprising that there hasn't been the number of consulting staff that you would need in an ideal world to back-up the junior staff, and a lot of the deliveries are inevitabley managed by junior staff with consultant cover from home. We need many more, probably three times the number of consultants staff than we've had over the last two years. And, the hospital's been either unable or unwilling to fund the employment of more people.

Speaker 10:

Yeah, it's good.

Speaker 1:

About a year before Jack Batton died, those problems bubbled to the surface under the leadership of a new chief executive. Michael [Moody] was head-hunted from Interstate. Not a doctor, but an administrator with a reputation for dragging health services into line. He was astonished, he says, when a couple of months into the job, staff came to him with serious clinical concerns about deaths and injuries to mothers and babies. So-called "adverse outcomes."

Michael M.:

Well, fairly early in the place, I was approached by a number of senior nurses that had worked in the facility for a long time, and they were expressing concerns about clinical management, or clinical practise, within the hospital, and I was staggard, to say the least, at the seriousness of it, and, also, in our capacity to deal with it.

Speaker 1:

The faults were principally in the obstetrics unit.

Michael M.:

The recurring themes that I was certainly picking up and putting together in my mind was the capacity for consultants to be called back to the hospital, to observe their availability, and the ability of the hospital to be in a position to call them in, supervision of junior staff, the clinical incident reporting, record keeping generally, in terms of clinical files, about keeping notes, about basic standards about those things.

Speaker 1:

He also heard of junior doctors fearful of being criticised for calling in a consultant. Delays in consultants coming in, communication breakdowns, and resistance to change. Doctors, however, reject the notion that there were any major problems.

Tim P.:

There's been no outstanding problem that we're aware of, or that's been brought to our attention, beyond the sorts of problems you'd expect in a hospital of this nature.

Speaker 1:

But hospital notes and doctors' correspondence show the same problems Michael Moody says he was hearing about had persisted for years.

Speaker 12:

Woo hoo! [crosstalk].

Speaker 1:

Already a mother of three, Debbie [Davey] gave birth to twins Matthew and Andrew at King Edward in August 1994.

Speaker 12:

Look, mama, look! [inaudible]!

Speaker 1:

Though Andrew is noticeably smaller than his brother, and both are small for their age, there's little sign now that they survived the odds to be here at all. The problems stated after Debbie was told she needed an early caesarian section to ensure the safe delivery of the boys.

Debbie D.:

And, I sort of psyched myself up, and I sincerely believed that at 36 weeks I was going to have the caesarian done.

Speaker 1:

Living in Busselton in the state's southwest, she was sent by her local doctor to a specialist in Perth at King Edward. Instead of a caesarian at 36 weeks, she was twice sent home by the specialist before finally being admitted to hospital.

Debbie D.:

Well I was actually 38 weeks by that time. I was very stressed about it, and, angry that it had been delayed that wrong, only after the advice I was given, and I was very, very worried.

Speaker 1:

There was every reason to trust the specialist, Dr. Brian [Roberman], a full-time member of the hospital staff and an experienced obstetrician who had personally delivered thousands of babies. Instead, Debbie Davey says the birth of her sons was a nightmare. Instead of a caesarian, Dr. Roberman induced her at 8:00 in the morning for a natural delivery, and she saw him only briefly after that. Nearly 12 hours later, there was still no sign of the twins, and a heart-monitor on Andrew was showing a prolonged slowing of his heartbeat. Dr. Roberman came in about that time, but left again. Another two hours later, at 9:30 p.m., worried staff telephoned Dr. Roberman, but he made no arrangement to come in.

Debbie D.:

Things were going on for too long. I know the staff were trying to get the specialist on duty at that time, and the specialist was not answering the phone or his pager, and the look of their faces, of the staff, I knew that I really did want that specialist in there doing something about the birth of the boys.

Speaker 1:

At 11:00 that night, 15 hours after the induction, Dr. Roberman was called again and finally came to the hospital. Half an hour later he delivered the twins, one by vacuum extraction and the other with forceps.

Debbie D.:

And, I remember when Andrew came out, I could feel him sliding over me, but I didn't hear him cry, I knew that he was in trouble, and I was told that Andrew had died twice in a minute. He'd died, and they got him back, and his brain was damaged, and he suffered many, many complications after the birth. He suffered cerebral haemorrhage, his blood wouldn't clot, and he also suffered seizures that caused a lot of problems.

Speaker 1:

Andrew was so ill they had him christened immediately, and held off on a birth notice in case it was to be a death notice instead.

Debbie D.:

Andrew, because of his brain damage, has speech problems, occupational therapy problems, he's developmentally delayed, he has cerebral palsy, he is on medication because he has [fidgets] of ADHD.

Speaker 12:

Mom, I want to swim.

Speaker 1:

The after-math of the twins' birth proved an unbearable burden for Debbie and her husband.

Debbie D.:

The birth of the boys is like a stone being thrown into a pond, and the ripples just get bigger and bigger. It's cost me my marriage, I had a very close-knit family, three very close children before the boys were born, and now I don't have the same respect because I feel that I never spent as much time with them as I should have, 'cause I'm so involved with my boys.

Speaker 1:

Debbie Davey has taken her case to a law firm well-versed in legal action against King Edward.

Speaker 15:

In terms of cases that are outstanding, that'd be about 15, of which there are about four cerebral palsy cases that we're investigating, a half dozen cases involving babies who've died whilst being delivered at King Edward, and there are a few other cases involving obstetric complications.

Speaker 1:

Dr. Roberman is cited in six of the 15 cases, many of which bear similar hallmarks.

Speaker 15:

If I was trying to say one thing which seems to be recurring, it would be the fact that there seems to be a delay in making a decisive decision about labour once difficulties are encountered. That seems to be the problem either, not intervening to deliver the baby by caesarian or something else. That would be the common thread in the cases that I've seen.

Speaker 1:

Just three months after Debbie Davey's case, Dr. Roberman was again accused of taking too long to attend a troubled birth. Once again, it's claimed there was a breakdown in communications between staff and doctor. The outcome, a severely brain-damaged infant, and a multi-million dollar lawsuit against the hospital. Eighteen months later, despite the concerns of senior staff, Dr. Roberman was made head of obstetrics.

In September 1998, five months before the new chief executive Michael Moody arrived, Dr. Roberman himself acknowledged in an internal memo there were major problems in the obstetrics unit.

Speaker 16:

"Morale is currently poor within the obstetrics service due to the enormous pressure of work. The rapid through-put of patients does not allow adequate care, and standards have fallen. Significant medical and legal problems have been encountered in the recent past. The potential payout is huge. The training of our registrars has reached crisis point. They have much less expertise when they reach their senior levels of training compared with registrars in past years."

Speaker 1:

Just two months after that memo was written, the hospital took the unprecedented step of appointing an in-house lawyer, Jennifer [Beck], to deal with the growing number of legal issues.

Jennifer B.:

I'd been working as a medical malpractice lawyer, I had just finished my insurance law at the master's level, I had clinical background as a registered nursing assist, and my father was a doctor. So I thought I had a lot to offer the hospital.

Speaker 1:

Jennifer Beck soon took up new and unexpected responsibilities. When Michael Moody controversially axed three executive director positions to save money, Jennifer Beck assumed the task of investigating deaths and injuries.

Jennifer B.:

From that point on I had total carriage of the adverse events in the hospital. I would make an assessment of the notification, if, for instance, if it was a stillborn which had arrived into the hospital, that would not require further investigation, but serious, serious incidents such as a brain-damaged infant or an infant that had died would require a face-to-face interview.

Speaker 1:

Both Jennifer Beck and Michael Moody found the reporting system on adverse outcomes to be ad hoc. What was your judgement  on how thorough the process was for reporting adverse outcomes?

Michael M.:

Well the process wasn't there. It was dependent on the individuals, there was no, there was a judgement , whether it was a poor outcome, and there was reasonably clear desire not to report.

Speaker 1:

Not to report, by whom.

Michael M.:

Well I think the culture of the organisation was the hospital administration didn't need to know about it, 'cause is was managed at the clinical unit level.

Speaker 1:

In May 1999, just after Michael Moody arrived, there was another shocking case that led members of the obstetrics unit to speak out. It involved a 20-year-old woman who was full term and undergoing what's called a "trial of scar," attempting to deliver the baby naturally after a previous caesarian. After a prolonged labour, it's claimed Dr. Roberman left the decision about whether or not to have a caesarian up to the patient without explaining the risks. After 27 hours of labour, the previous scar split, and the baby tore through the woman's uterus, despite an emergency caesarian, the baby suffered massive brain damage and died three weeks later. That case is also in the hands of lawyers.

Jennifer B.:

Well, I had very senior members of the obstetrics unit come to me with grave concerns in the obstetrics unit, in particular delivery suite and labour ward, and I had to advise the chief executive of these problems. There was never any option for me to keep this information to myself, I'm an officer of the court, and there is only one way I can act, and that is the right way.

Speaker 1:

Nine months before the Battons came into Kind Edward, Jennifer Beck wrote an emotive letter, claiming the standard of care in the labour ward and delivery suite had significant ethical, moral, financial, and legal implications for the hospital. In sub-headings such as "Dead Baby" she listed five cases of death or injury to infants. She cited poor decision making by Dr. Brian Roberman, a lack of supervision of junior doctors, inadequate after-hours care, and an institutionalised malaise that had led to a reluctance to change.

Tim P.:

The staff felt very uncomfortable about being invited into her office, and questioned closely about events that had happened,

Speaker 1:

Why?

Tim P.:

Well, her style is confrontational. There was a feeling that if any false steps were made, if anything adverse happened, that we'd be pounced upon, and that doesn't encouraged people to do their best.

Speaker 1:

Do you think now that you overreached your role?

Tim P.:

Absolutely not.

Speaker 1:

Could you have done anything else?

Tim P.:

No, I would do the same thing again if faced with those problems, which I hope I never am.

Speaker 1:

After quietly hiring inter-state consultants to examine the hospitals incident reporting and management, Michael Moody went to WA health authorities.

Speaker 18:

On or around the ninth of December 1999, the chief executive officer of the Metropolitan Health Service board, and the chief executive asked me to come to another meeting in which they could present some documentation, and that documentation did appear to indicate that there may be problems with clinical practise and processes within the hospital.

Speaker 1:

When the state's chief medical officer then ordered a clinical review by a senior obstetrician and midwife from outside WA, doctors felt they were under an attack instigated by their own chief executive.

Tim P.:

If you have a situation where people who have never taken responsibility for someone's life in their professional lives themselves turn around and say, "You've done a bad job, you've stuffed this up, this baby shouldn't have died, this baby shouldn't have been damaged," it's extremely distressing, and I think the staff are under enough stress already without this sort of unprovoked, unwarranted attack on their professionalism and their credibility.

Michael M.:

I think that there was an expectation that I would go to them, and certainly in their perception, and have the matters resolved internally and quietly. My defence of that is I had many discussions with many senior clinicians about the matters, they were not prepared to come out and publicly support me internally in the organisation about the things that needed to be done, because they were inheriting conflicts with their colleagues.

Speaker 1:

News of the erupting conflict at King Edward [crosstalk] hadn't spread as far as the countryside where Dean and Sadie Batton were enjoying the first few months of her pregnancy.

Dean:

It's okay,

Sadie:

It's all right.

Dean:

It's okay. It was something we thought, "This is great, this is terrific, we have the perfect situation with the farm, the job's very stable, it's a great place to bring up a child," and when we found out that Sadie'd actually conceived we thought, "Terrific, this is it, this is the start."

Sadie:

I showed him the little pictures ...

Speaker 1:

Sadie Batton began a diary within days.

Sadie:

He was so happy, on cloud nine, now it's a matter of heads down, healthy eating and drinking, good thoughts, exercise, and enjoying the pregnancy together. We wanted to tell everybody ...

Speaker 1:

Sadie had earlier undergone surgery for cervical cancer, and was told she'd need a caesarian so as not to disturb the cervix further. Six months into an otherwise uneventful pregnancy, Sadie suddenly went into labour. As they saw it, they were lucky to be closer to town than on the farm. They'd spent the afternoon picnicking at [Freemantle] when her waters broke.

Sadie:

I checked with Sadie, I said, "You okay?" She says, "Oh, I'm just contracting," and she had towels wrapped between her legs, and it was just wet, and, so we jumped in the car, and I was starting to get a bit flighty, so, I rang triple zero and got in contact with police communications.

Speaker 19:

Police emergency.

Dean:

Hello, I've been trying to get in contact with King Edwards Memorial Hospital,

Speaker 19:

Right.

Dean:

Right, we're just travelling towards there now, my wife's 26 weeks pregnant, her water's broken, she's been in pain most of the day, she's got cancer of the cervix, and the closest hospital to where we are is King Edwards so we're going there now.

Speaker 19:

Okay, I'll let them know that you're coming.

Dean:

Thank you very much.

Speaker 19:

Okay.

Dean:

Cheers.

Speaker 1:

So King Eddie was the best place to go.

Dean:

The only place to go.

Speaker 20:

[inaudible] Women's Health, King Edward Hospital.

Speaker 19:

Yeah, hi, city constable [inaudible] from the police operations centre.

Speaker 20:

Yeah.

Speaker 19:

Just had a Mr. Batton ring up,

Speaker 20:

Yeah.

Speaker 19:

To let you know he's bringing his wife in,

Speaker 20:

To emergency?

Speaker 19:

Yeah.

Speaker 20:

Okay, I'll put you through then.

Speaker 19:

Thank you.

Speaker 1:

It was the evening of March the 15th, within days the visiting clinical review team was due in to examine the obstetrics unit.

Speaker 21:

Hello emergency?

Speaker 19:

Yes, hi, city constable [inaudible] of the police operations centre.

Speaker 1:

There'd been intense discussions in recent weeks about adverse outcomes, [crosstalk], clinical practises, and the lack of supervision of junior doctors.

Speaker 21:

He's actually gonna have to go up to the labour ward, I'll see if I can transfer you up there, hang on a second.

Speaker 19:

Okay, thank you.

Speaker 1:

It was a time when you might expect the hospital to be on its toes.

Speaker 22:

Can I help you?

Speaker 19:

Yes, hi, city constable [inaudible] of the police operations centre.

Speaker 1:

In the Batton case, the factors all added up to a high-risk birth. The baby was very premature, there were signs he was in distress, and it was a very junior doctor.

Speaker 19:

He's been trying to get through to you, he's on his way in.

Speaker 22:

All right, we've not had the phone ringing at all.

Dean:

We now know that the junior registrar that dealt with us first was three months into his first year. There was two midwives there at one stage, and they said your baby's going to be born tonight.

Speaker 1:

The junior registrar rang the consultant on call, Dr. Brian Roberman, for advice around 7:50 p.m.

Sadie:

I kept asking the midwives, "What are we waiting for? Are we waiting for somebody?" And they said, "Oh we're waiting for somebody more experienced, to come in."

Speaker 1:

And what was the atmosphere like at that time.

Dean:

Tense.

Sadie:

It was tense, people going in and out all the time. They kept the heartbeat monitor on me all the time, and they kept reassuring us and saying, 'cause you know you could see it on the screen, the heartbeat monitor and you could hear--

Dean:

Strong.

Sadie:

Hear Jack's heartbeat.

Dean:

Really strong heartbeat.

Speaker 1:

But the situation was deteriorating. Jack's heartbeat had slowed, and attempts to delay the birth had failed. The experienced midwives were becoming frustrated that no doctor was intervening to deliver the baby.

Dean:

From 7:30 to 8:00 the junior registrar,

Sadie:

He was--

Dean:

Didn't do very much at all, he sat in the corner.

Sadie:

It was though, he wasn't really interested.

Dean:

It was though as if he was waiting for someone to turn up.

Speaker 1:

By 8:30, it had become clear, to the midwives at least, that a decision had to be made. One urged the registrar, "Please deliver this lady, or she may never have another live baby." The junior registrar rang a senior registrar to come in, only to have her misdiagnose the baby was lying in the womb, and make a failed attempt at delivery. Precious time was slipping away.

Sadie:

I think by 9:00, things had gone too far, really.

Speaker 1:

What they didn't know, was the junior registrar had telephoned Dr. Roberman over a period of two hours, not once, or twice, or three times, but four times. Finally asking him on the fourth call explicitly to come in. When Dr. Roberman arrived, it was after 9:45 p.m.

Dean:

And everything just went into emergency mode.

Speaker 1:

Jack Batton was finally delivered by emergency caesarian at 11 minutes past 10:00. His tiny body was severely bruised, and his right leg had been broken either during an attempt to turn him in the womb or during the caesarian. He was put on a ventilator to keep him alive, but it was apparent to all that Jack was dying.

Dean:

We all knew that basically the decision had to be made to take the tube out of Jack and Jeff said, "He's not going to survive. We've kept him alive to bring Sadie down." And we just agreed to have the tube taken out and ... They passed Jack over, and he just died really quickly.

Speaker 1:

Jack survived less than three hours, and the cause of death was listed as intrapartum asphyxia. He had been starved of oxygen during the delivery.

Sadie:

His legs were bandaged together as one had been broken. He had a cut from the corner to his mouth, and damage to his lung. They had kept him alive whilst I was coming round, and now his heartbeat was so weak, but he looked beautiful. He was our little boy, our special man Jack. The doctor took out the tube, and our little man slowly gave up his fight. He was born at 10:11 p.m., and died shortly after midnight. Even though it was a very sad time, it was a special bonding time, it was so peaceful.

Speaker 1:

Jack weighed 915 grammes, a healthy size for his gestation, and bigger than many of the other babies that survive in the neonatal ward.

Dean:

There was one midwife that came in on the, that morning, I think, and she had two days off since Jack's delivery, and she came in and went over to Sadie's right-hand side of the bed and just started crying, and she just said, "I've never--

Sadie:

She was just saying, "Sorry," she was just saying,

Dean:

Saying, "Sorry," [crosstalk].

Sadie:

What are you sorry for?

Dean:

She said, "In all my experience as a midwife, don't think that what happened that night was normal."

Speaker 1:

Alarmed by the case, the hospital lawyer did what had never been done before, reported the death of the baby at King Edward to the state parliament.

Dean:

Nobody wanted to talk to us. We approached Michael Moody, the chief executive officer. Eventually we got to meet him, and during that meeting he said, "Your son shouldn't have died."

Sadie:

And he advised us to get a lawyer.

Dean:

Yeah. He advised us to get a lawyer,

Sadie:

Which we had already done.

Dean:

He said, "Your son shouldn't have died because the country's designed to save children like that.

Speaker 1:

At the coronial inquest into Jacks' death, the series of mistakes that night became clearer. An inexperienced registrar, Dr. Michael [Gannon], out of his depth. A senior registrar, Dr. Miriam [Lee], arriving on the scene, and causing confusion with her misdiagnosis of the baby's position.

Dean:

Given the evidence that we've got now, we see there were so many mistakes made it's scary, it's very, very scary.

Speaker 1:

Finally, retired expert obstetrician Dr. Frederick [Hind] insisted Dr. Roberman should have attended the hospital sooner, after the second phone call.

Dean:

The on-call consultant at the time just happened to be the head of the obstetrics department, who lives three minutes away, and given the information that he had a very, very inexperienced junior registrar, dealing with a mother who's severely premature, 25 weeks, 26 weeks, meconium draining, contractions severely going from three minutes.

Speaker 1:

What should have happened?

Dean:

Well I would have taken the time to just drive down to make sure he was okay, I wouldn't believed that's duty of care, I believe in medical circles, anybody with due diligence would have taken the duty of care to drive down to make sure this inexperienced junior registrar was okay and not drowning.

Speaker 1:

In his defence, Dr. Roberman insisted that at no time was he asked to come earlier. Nor was he made fully aware of the deep concerns of the midwives. But so conflicting was some of the evidence between Dr. Roberman and the junior registrar, the coroner believed that either Dr. Roberman had lied in court, or the registrar had grossly misunderstood his senior doctor. Either way, the coroner held Dr. Roberman responsible.

Speaker 23:

Dr. Roberman asked me to point out that he's extremely sorry for what happened on this night, otherwise ...

Speaker 1:

Jack Batton was born at 25 weeks and four days, well short of the full 40 weeks, and he was born at the one hospital in the state that made it its business to save babies as tiny as Jack.

Debbie D.:

When I saw that particular case, I thought to myself straight away as soon as I read it, the same mistakes are being done six years down the track, and I felt very much for the mum and dad and for the little baby, and I thought, it's still happening, and it shouldn't be.

Speaker 1:

And you've never spoken out before, is that part of the reason you're doing it now? Because the mistakes were still happening?

Debbie D.:

Yes. I don't want this to happen to any more babies, and the effect that it does to the parents, the grandparents, and if there's other children, I don't want this ever to happen to anybody else.

Speaker 1:

Within days of Jack Batton's death, the visiting clinical review team had finished its investigation, and found the obstetrics unit seriously flawed. It listed a poor reporting system for adverse outcomes, junior doctors not adequately supervised, and fear of asking consultants to come in.

Jennifer B.:

Once the review was announced, I stopped in at the cafeteria, people started avoiding me, I would walk along the corridor and people would turn the other way. I was basically, I was shunned, I was marginalised, people were avoiding me.

Speaker 1:

Shortly after, the West Australian health minister announced a formal inquiry, headed by Perth lawyer Neal Douglas. He'll examine the hospital's clinical practises for the last decade, looking at more than 500 cases. In the meantime, the hospital has 27 lawsuits pending, with dozens of other couples threatening to sue.

Tim P.:

Despite the lack of funding over the years and the lack of staff, lack of support that we've had, the lack of infrastructure for the last 20 years, our results are still extraordinarily good. So if we can be got at and attacked and vilified, and made to look like incompetent, bumbling fools that try to cover their tracks afterwards, then any hospital in the country is vulnerable.

Speaker 1:

It had become a war in which every side claimed it was the victim, and no one accepted responsibility. Doctors allege the whole affair had been brought on by chief executive Michael Moody who'd been hired in a deliberate attempt to bring down the hospital.

Tim P.:

I don't think it was any secret that the people at the top areas of the health department have wanted to get this place either demolished, or downsized, or moved elsewhere, and we're keen for a process to be set in place whereby the spirit, if not the fabric of the place, would be destroyed by bringing it into disrepute.

Speaker 1:

Michael Moody rejects the notion he was appointed with any agenda and insists he was simply doing his job.

Michael M.:

I was in a position where I had to take what I believed to be certain actions that upset that equilibrium, but I don't have any regrets about the things I've done, I'm very comfortable with what I did.

Speaker 1:

Finally, seething over Michael Moody's management, doctors went directly to the Premier Richard Court demanding, and getting, Michael Moody's removal. They threatened they'd use their political power at the polls in the lead-up to last weekend's election. Months later, Jennifer Beck was sidelined, and both she and Michael Moody have now been relocated to the health department.

Jennifer B.:

I had a great sense of relief when I left the hospital, I had a very difficult and harrowing 12 months there.

Speaker 1:

For weeks, Four Corners has asked Dr. Brian Roberman to discuss issues raised in this programme. Just hours ago, he submitted a brief written response, restating that he was not explicitly asked to attend Sadie Batton until the fourth phone call, and that he gave appropriate advice on the telephone. He says he was not told of foetal distress. He blames funding issues for hospital problems, and says the critical review of the obstetrics unit was flawed and on-sided.

Tim P.:

I think he's been treated very unfairly, I think he's been denied natural justice, and he is one of, three, four times at the hospital, I mean, I don't work in the area of obstetrics, so I can't comment exactly on his workload, but it's enormous, and I think he's received a very poor deal, and has been unfairly treated.

Speaker 1:

Days ago, the hospital said Dr. Roberman would relinquish his hands-on role in the labour ward. Today, that changed with a statement saying he would continue to deliver babies.

Speaker 25:

It's just me again, listening to your baby, okay.

Speaker 1:

Beneath it all has been a hospital struggling to continue its job, to deliver healthy babies, an average of 100 a week.

Speaker 25:

Just breath, just breath. I'll cut his cord here.

Speaker 1:

The bitter debate about one [crosstalk] at the hospital, had damaged the reputation of an entire public institution, and the casualties have been staff morale and public confidence.

Speaker 26:

Oh he just doesn't [inaudible], we love you so much.

Speaker 1:

A new acting chief executive is making changes to improve the reporting of adverse outcomes, and to give junior doctors the support they need, especially after hours. But the damage the controversy has done to the public faith will take longer to fix.

Speaker 27:

I think it's been a tragedy. A tragedy for the hospital, a tragedy for the health system, and more importantly, a tragedy for the whole of the women of West Australia.

Speaker 1:

It was 8:00 on a hot Perth morning when Dean and Sadie Batton set off to hear the coroner's verdict on Jack's death. Coroner Aliester [Hope] found Dr. Brian Roberman needed to come to the hospital after the second phone call. He criticised the confusion, poor communication, errors, and delays, saying the doctors should have listened to the midwives. But he was faced with evidence that Jack was so premature and gave such signs of foetal distress a caesarian any earlier on Sadie may not have saved him anyway. He found, therefore, that essentially, it was death by natural causes. Given the litany of mistakes, the coroner found, his verdict devastated Sadie and Dean Batton.

Dean:

We feel grossly disappointed with the coroner's decision, we feel the decision has just put other mothers and children at risk, and our heart goes out to them.

Speaker 28:

[crosstalk] Before you go, do you think there's more to be said about the lack of communication ...

Sadie:

Today we'd hoped that it might have gone to the medical board.

Dean:

That somebody would be made accountable. Nobody's been made accountable for what happened on that night.

Speaker 1:

When you heard the finding that it was a natural death, what did you both think?

Sadie:

Just mad. Just wanted to burst into tears.

Dean:

Yeah.

Speaker 1:

And you did that later?

Sadie:

Yeah.

Dean:

There was nothing natural about Jack's death. It just means that there's a possibility that other deaths can be brushed underneath the carpet, I believe Jack was a great opportunity, a catalyst for change, and now I believe the door's back open wide for adverse events to be swept under the carpet.

Speaker 1:

What's in here?

Sadie:

There are a few of his special things.

Speaker 1:

After sitting through their son's inquest, the Batton's are still puzzled at how a hospital clearly undergoes close scrutiny managed to repeat the same errors that had surfaced so many times in the past. Clearly, any one avoidable death before then should have been a catalyst for change long before Jack Batton's mother ever made it to hospital.

Sadie:

Dean had a bit of a bad day Friday, it makes us both mad, all that has happened, it effects us both in different ways. I wish neither of us had gone through what happened on the 15th and 16th of March. It has taken away a big part of our spirit, and it's so hard to put it behind us.