Incompetent and untrained public hospital staff kill young mother

Very dangerous to have a medical emergency in a public hospital -- where responsibility stops nowhere and where supervision is minimal -- despite hordes of "managers"



REBECCA MURRAY was pregnant and healthy when she was admitted to Bathurst Hospital, but a day after delivering her third baby by caesarean the 29-year-old was dead. She had hemorrhaged, but nurses only realised when they saw her bloodied sheets.

Two weeks earlier, the 36-week-pregnant mother and her husband, Jim, had posed for this family photo with their son and daughter, Emelia and Lachlan, who were awaiting the arrival of a brother or sister. On June 24 last year, however, Mr Murray was in the waiting room of the old Bathurst Hospital, relieved that his newborn daughter, Grace, was healthy but unaware that down the corridor his young wife lay dying after a series of preventable errors.

A NSW Health incident report reveals that Mrs Murray had been transferred to a recovery ward after a routine caesarean when her blood pressure dropped dangerously low. Nurses should have called a medical emergency team but instead left her bleeding. The report admits that the nurses were so inexperienced they did not know how to recognise a postpartum hemorrhage.

It was more than 30 minutes before hospital specialists arrived, and Mrs Murray was taken back to theatre for surgery. She needed a blood transfusion after losing huge amounts of blood, but the incident report concedes that two vital blood-warming machines were faulty. Both "kept turning off for no identifiable reason". Worse still, theatre staff did not know how to use one machine and didn't know the password to operate it, the report said. Soon after, Mrs Murray suffered a cardiac arrest in theatre and doctors decided to transfer her to a metropolitan hospital. She was taken to the intensive care unit at Nepean Hospital. But, by 10.50am on June 25, she was dead.

The report concluded the "inadequate information exchange between treating clinicians contributed to a delay in recognition of the obstetric emergency" and "the rural base hospital medical records did not include an accurate record of blood loss, blood product and fluid replacement".

A new $98 million Bathurst Hospital opened in January, but surgeons suspended routine elective surgery last month, warning that serious design and construction flaws - such as an inadequate emergency alarm system and a pipe that leaked raw sewage into the maternity ward - were putting patients at risk.

Mrs Murray's death has been referred to the Health Care Complaints Commission and the coroner. But Mr Murray, left alone to raise three children, is demanding an apology from NSW Health and has not ruled out legal action. "This isn't a Third World country where a woman who is healthy goes in to have a baby and never walks out of those hospitals to kiss their kids goodnight again," Mr Murray told a news conference at State Parliament with the Opposition yesterday. "My kids have to grow up having no mother. I believe she should still be alive if things had been done properly."

The Opposition health spokeswoman, Jillian Skinner, said it was a tragic example of systemic problems. "How is it that massive blood loss goes unattended in a NSW hospital?" In Parliament, the Health Minister, Reba Meagher, said her sympathies were with Mr Murray. But she said the Opposition could not attack the entire health system because of one tragic case. "I am advised that Mrs Murray suffered acute complications following the birth of her child and was transferred to Nepean Hospital, when her condition continued to deteriorate after extensive treatment," Ms Meagher said. "While any maternal death is tragic, it is also extremely rare." Whenever Mr Murray takes his children to visit their grandparents, he says, they think they are going to visit their mother - "asleep" in the hospital.

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Improving Aboriginal education needs big rethink

JULIA Gillard's plan to fund 200 additional teachers with $100 million of support is a commendable response to the Northern Territory's crisis in indigenous education. But the Education Minister has been poorly advised. The proposed measures will not come close to delivering indigenous literacy and numeracy. It would be better to identify effective solutions now than have to make another apology in 20 years.

For the past two years, the NT's Department of Employment, Education and Training has reported years Three and Five literacy benchmark pass rates of about 90per cent for non-indigenous children. For indigenous children in Darwin and Alice Springs, the pass rate drops to 60 per cent. But for indigenous children in remote areas, the rate crashes to just 20 per cent. Even this pass rate is overstated: most of the children attending the 62 homeland learning centres have not even been tested for years Three and Five benchmarks.

Thirty years of welfare dependence with attendant alcoholism, drug abuse and violence in indigenous communities have played a role. Poor school attendance also has been blamed for poor results. But most indigenous parents are desperate for real education for their kids. NT school enrolments for 2008 appear to be higher than the 2006 census data (which admittedly probably undercounted the indigenous population) indicate.

The main reason for poor attendance is that many indigenous people are offered pretend education: the product of pseudo-curriculums and inadequate teaching. In the few schools where there are effective teachers who ignore the official curriculum for indigenous children, they attend school and pass the tests.

The separate curriculums followed by indigenous schools are a form of apartheid. When children of non-English-speaking immigrants enrol in Darwin schools, they follow the mainstream curriculum but take English as a second language programs. Indigenous parents in the Top End want their children taught the mainstream curriculum in English from kindergarten so they can get jobs and participate in society. They know that only literate communities can preserve traditional languages in the modern world. All commonwealth funding for education in the territory should depend on the condition that indigenous children are not intellectually segregated but taught the same curriculum as other children.

The absence of indigenous teachers in the NT is another indicator of educational failure. The NT's population is 28 per cent indigenous but, of 4572 registered teachers there, only 164 (3.6 per cent) identify as Aborigines or Torres Strait Islanders. Of these, only 63 (1.4 per cent of the total) have completed the normal four-year course of education required to qualify as a teacher. Most of the other 101 indigenous teachers have been registered (together with another 600 non-indigenous teachers) without such qualifications. These 700 underqualified teachers are concentrated in the 62 learning centres and in the community education centres that act as substitutes for schools in predominantly indigenous communities. These teachers have not been assisted to upgrade their qualifications to present standards and there is no provision in the new commonwealth legislation for them to do so.

The bill allocates $18.4 million for the creation of 190 education department jobs for former Community Development Employment Program participants, a change long overdue. In contrast to teacher aides in mainstream schools, who help children in classes taught by qualified teachers, indigenous teacher aides in learning centres are often the only people in front of the class. Many of the CDEP teacher aides would not pass the Year Seven literacy test. What steps are being taken to assist these teacher aides to become literate and numerate?

The planned funding does not include housing for additional teachers outside Darwin. At present NT housing costs, this would require another $22.5 million in 2008 and $67.5million by 2011. Such funding - $90million in total - would almost double the planned commitment.

Because of past policies, more than 5000 of the nearly 8000 indigenous teenagers in the NT cannot pass the national literacy benchmarks. Nor could another 5000 men and women in their 20s. The accumulated backlog of insufficiently literate indigenous young people is 10,000. They represent the future of indigenous communities.

No part of the present education system can accommodate teenagers with Year One literacy. They cannot sit side by side with six-year-olds or in a class of teenagers from the mainstream education system. To bring these indigenous teenagers to the stage where they could access mainstream jobs and further education would require one or two years of sheltered accommodation in an English-speaking environment, intensive tutoring and part-time employment. The minimum cost would be $50,000 a year for each student. The real cost of remedying past failed policies would therefore be $500 million to $1 billion.

There is clearly a lack of any remedial action on this scale. Even partial solutions will require more funds than have been committed. Parents of students who do not pass benchmark tests are entitled to vouchers worth $700 a year to have their children tutored. This program assumes literate parents and access to qualified tutors. Parents in one remote indigenous community have therefore asked the federal Government if they can aggregate these vouchers and use them together with foundation funds to pay for a remedial teacher for their children. They have not even received the courtesy of a reply.

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Plastic bag bans absurd

Plastic bags are under siege, pilloried globally as a menace to the environment and a symbol of man's conspicuous consumption, despite mounting evidence to the contrary. Without plastic bags we would all buy less, goes the thinking. But, of course, we won't. Hence you have the ludicrous situation at Bunnings where a customer buys a small, but nonetheless unwieldy bag of potting mix (in dirty plastic wrapping), a tape measure, a paint-sample pot, marker pens, pest oil and a bottle of Thrive, and is expected to carry it all out of the store in her arms, thus making filthy her white shirt, because Bunnings is a good environmental citizen and no longer provides plastic bags, or only reluctantly and for 10 cents a piece.

Australia's chief bag-slayer is our Environment Minister, the lantern-jawed former rock god Peter Garrett, who has little of substance left in his portfolio after the meaty bits were handed to Penny Wong. But his caged activist persona is just perfect for the kind of empty symbolism which has marked the Rudd Government's first 100 days. When it comes to evil Japanese whalers and plastic bags, Pete's your man. His first big act in office has been to declare bags would be banned or taxed into oblivion by year's end, and he has convened a summit of the nation's environment ministers next month to achieve that end. Jumping the queue on Sunday was South Australia's Premier, Mike Rann, who announced a ban on bags from next year. "I am urging all states to follow this important step in ridding our environment of these bags that contribute to greenhouse gases, clog up landfill, litter our streets and streams as well as kill sea life."

All very virtuous-sounding, except none of it is based on fact. The Productivity Commission did a cost-benefit analysis in 2006 on the merits or otherwise of plastic bags, and found they comprise just 2 per cent of litter and it was not certain if they damaged animals. The commission claimed plastic bags may be eco-friendly in solid landfill, because of their "stabilising qualities, leachate minimisation and minimising [of] greenhouse-gas emissions". Three-quarters of us recycle the bags as bin-liners, pooper-scoopers or carry bags, thus confining stuff that might otherwise become litter.

But, as usual, green hysteria obscures the truth. For instance, Planet Ark's founder, Jon Dee, was quoted in 2006 saying he had been "inundated" with calls from farmers whose calves had died after swallowing plastic bags. But the National Farmers Federation has never heard of such a thing, a spokesman said yesterday. Nor has the Cattle Council of Australia had a single report.

A 2002 Newfoundland study of 100,000 marine animals killed each year, which is widely cited by green groups as proof of the evils of plastic bags, turns out to have been wildly misquoted. The deaths were actually attributed to fishing nets. So ban fishing nets. And since cigarette butts comprise almost half of Clean Up Australia's rubbish collections, why not ban cigarettes instead of plastic bags? Unlike bags, fags are not useful, and there would be the long-term benefit of improved health.

In an attempt to fend off draconian bans, retailers have been getting stingy with plastic bags and making bucketloads on green imported Chinese faux-enviro-bags. We can live with that, but what is intolerable is the fact that so many plastic bags have become so flimsy they are next to useless for anything heavier than a Paddlepop. At my local shop an irate women recently marched in to demand a new bottle of soft drink after the one she had just bought fell through a hole in the bag and smashed all over the floor of the fish-and-chips store two doors up. Whose fault is it that the bag was a disaster, what was the customer's duty of care, and who should compensate the poor fish-and-chips shop owner for his sticky floor? Such are the great questions thrown up by the looming ban on plastic bags.

There is nothing about banning plastic bags that makes sense, yet it is a global craze, latched onto by lazy governments desperate to appear green. The tragedy is that while the ban will do little for the environment, it will ruin Australian businesses which make and recycle the bags. The largest manufacturer, Melbourne's Detmark Poly Bags, makes almost all the Australian checkout bags used by retailers, including Woolworths. Detmark, a 25-year-old private, Australian-owned company worth $15 million to $20 million, with about 30 workers, will be "just wiped out" if the Government's plastic bag ban is enforced, its managing director, Malcolm Davidson, said yesterday.

He points out the ethylene gas which is turned into ethylene pellets from which he makes his bags, is a byproduct of natural gas from the Bass Strait, piped to a processing plant in Melbourne. "If we didn't use the gas they'd have to burn it off", hardly a Gaia-friendly solution. Repeat Plastics Australia (Replas) is another successful Australian-owned company that will be hurt by the ban, since the fewer plastic bags available for recycling, the higher the price of the raw product. It turns plastic bags into everything from horse feeders to jetty planks, park benches to bollards.

"The plastic bag is a perfect product," said the company's national marketing manager, Mark Jacobsen. "It's 100 per cent recoverable, 100 per cent recyclable, cheap, practical. It would have to be one of the best products ever invented . The public is being hoodwinked into thinking plastic bags are bad . when the problem is [some people] are not disposing of them properly."

There is now such a shortage of waste plastic for recycling, he says prices have doubled in the past 18 months. "We are crying out for plastic," he says. "This has put the recycling industry back 50 years. How illogical can you get?"

As for the thick green so-called eco bag, which Garrett has described as "canvas", it also is a plastic bag, made of polypropylene. Each is the equivalent of 1000 of the original polyethylene bags, Jacobsen says. And "no one wants to recycle them," as the plastic requires a higher temperature to melt. The bags rip and soil like any other bag, despite the hype, and at some point they must be disposed of. They might not do much for marine animals, but someone is making a lot of money out of them.

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Dysfunction defines the NSW department of lost children

Short of frontline staff but overflowing with bureaucarts

KATE ran away from home when she was 14. She insists she isn't exaggerating when she says she has moved "about 100 times" in the five years since. Sometimes the NSW Department of Community Services moved her. Sometimes she just took off. Sometimes she misbehaved and got herself expelled, says Kate (not her real name). "If it's your behaviour, they kick you out that second, although you've got nowhere to go. "I never really got to be a normal teenager," she says. "I didn't go to the one school. Nothing was ever permanent. I always had stuff that fitted into one bag, because I was always prepared to move."

There are about 12,700 children and young people in out-of-home care in NSW, including the "high-needs kids" whose behaviour is almost unmanageable. A DOCS official who spoke to Inquirer on condition of anonymity says the department pays "as much as $15,000 a week to have one of these kids babysat by a non-government (welfare) agency".

Most observers agree DOCS ranks poorly against human services departments in other states. Yet the department's constant air of crisis makes the front pages only when a child "known to DOCS" dies in suspicious circumstances. The department is now under scrutiny at the Special Commission of Inquiry into Child Protection Services in NSW. The inquiry was called following the death of seven-year-old Shellay Ward, an autistic child who allegedly starved to death, one of a number of deaths in recent months involving young children repeatedly reported to DOCS.

Under mandatory reporting legislation in most states, police, teachers, childcare workers and doctors are obliged to report suspected abuse or neglect. In NSW they contact a central helpline to report on children who have been harmed or are thought to be at risk of harm. There were 286,033 such reports in 2006-07, three times as many as in 1999-2000. Nearly half were from police, who contact the DOCS helpline following any incident of domestic violence where a child is present, irrespective of the seriousness of the incident or whether the child is involved.

Figures from the NSW Child Death Review Team show that the number of children in NSW who have died from fatal assault has shown little variation since 1996, but the number of notifications of suspected child abuse has gone through the roof.

Andrew McCallum, chief executive of the Association of Child Welfare Agencies in NSW, calls mandatory reporting "a perverse mechanism which drives up reports but doesn't do much to assist in the protection of children". "Everyone feels good about it," McCallum says. "But what it does in reality is overload the system, as we've seen in NSW."

Surveys organised by the Public Schools Principals Forum revealed that principals who contacted the DOCS helpline did so to no avail nine times out of 10. "Fewer than 11 per cent are being actively responded to by DOCS," says retired principal Brian Chudleigh, deputy chairman of the organisation. That left many principals ringing the helpline repeatedly. Chudleigh recalls hearing of a child at a school in the far west of NSW who was 11 years old the first time the principal reported him. "The principal told us how this child frequently came to him begging him not to send him home because he was afraid of his violent father." But the principal reported on the same boy three years running without hearing anything about it from DOCS.

Shortly before Christmas, a departmental officer asked an executive from a non-government agency if the agency could step in on a contingency basis to replace departmental officers working in the field. The agency was being asked to deal with families reported to DOCS for the first time. The executive says that DOCS was so short of front-line staff that its officers could only go from one child abuse notification to the next. Things are very different in the department's headquarters in the inner Sydney suburb of Ashfield, which is jam-packed with senior officials.

The department's director-general Neil Shepherd, who is retiring next week , came into the job in 2002 from the Cabinet Office, and had the clout to convince the state Government to give the department an additional $1.2 billion over five years. The results were certainly evident in Ashfield. The hierarchy answering to Shepherd and his four deputy directors-general includes eight executive directors, 36 directors, 17 managers and eight regional directors, and legions of assistant directors, unit managers and program managers.

"Neil Shepherd wanted to do something about the closed-shop culture," the DOCS official tells Inquirer. "He wanted fresh blood and brought in people from other departments. He may have had all the best intentions. But having people come from outside just because of their management skills isn't good enough. "Many don't have a clue about child protection. But they are the ones writing policy. Instead of reviewing old policies and what's happening, they write a new one. We have hundreds of new directions, new policies, new guidelines." Despite the constant chopping and changing, "you don't see much difference", says Gary Moore, former chief executive of the NSW Council for Social Service. "That's partly the culture of the organisation, the dysfunctional way it operates."

DOCS has employed about 1000 more caseworkers in recent years, according to a press release from Community Services Minister Kevin Greene. But the DOCS official, from an office out in the field, says the new project officers and managers generate so much paperwork that front-line staff, already swamped by thousands of notifications, have less time to spend with vulnerable families and children than they did in the 1990s. In those days front-line staff spent about 70per cent of their time with them, he says. "Now workers spend about 40 per cent of their time on face-to-face contact with families and 60 per cent on reports, phone calls and meetings."

Those figures go some way towards explaining the high staff turnover, says Jacqui Reed, chief executive of the Create Foundation, which works on behalf of children in care. "Instead of working as social workers, they're pen-pushers filling in reports." But the paperwork may be just that: paperwork. "I've never expected, nor have I got, anything out of making a report," says a psychologist who has worked for DOCS. "Making a report doesn't lead to a tangible outcome. You do it because it's the law."

In NSW each year between 13,000 and 14,000 children are found to have been harmed or to be at risk of harm, says Judy Cashmore of the University of Sydney's law faculty, an expert in the field. "About 3600 of them go into out-of-home care each year, but whether they go into care or not, we know next to nothing about what happens to them over time."

Though much of the inquiry into child protection has been held behind closed doors, the public forums conducted by commissioner James Wood QC highlighted the fact that mandatory reporting is a one-way process. "We are legally bound to give all the information we have, but we get nothing in return," Chudleigh says. "Schools make the report, then are shut out."

Before the helpline, schools concerned about children who appeared to be neglected or abused would contact the local DOCS office and work with it to try to resolve the problem, Chudleigh says. Such initiatives have been replaced by processes, as human problems are described on forms that can withstand legal scrutiny, not to mention headlines, whether or not they change the situation.

The psychologist says: "The fear is not so much that mistakes will be made but that they will be revealed." It may be that the ceaseless tinkering reflects the fact that DOCS has an almost impossible task that it's meant to perform to increasingly unrealistic standards. "The expectation is that we are going to prevent child abuse," the DOCS official says. "We can't prevent it any more than the police can prevent a crime."

Victoria also has mandatory reporting but the number of notifications barely changed in the eight years that notifications in NSW trebled, according to figures from the Australian Institute of Health and Welfare. Bernie Geary, Victoria's Child Safety Commissioner, warns against complacency, saying it doesn't make sense to compare the figures from state to state "because the criteria around the system of reporting deaths from abuse are different". But many believe that Victoria is doing better by assisting families before there's a crisis. According to McCallum: "Fewer children are coming into care in Victoria. Yet there are also fewer kids requiring intervention by child protection staff. The Victorian Government handed almost everything but child protection to non-government agencies. "It made the distinction about who did what very clear. The result is you have fewer people coming into the child protection system. You have non-government agencies working alongside child protection workers to try to get alternative services to taking kids into care."

It is regularly said that in concentrating the role of its Department of Human Services Affairs on forensic child protection, Victoria has done what so clearly needs to be done in NSW. But the immense practical problems such genuine restructuring would involve are minute compared with the philosophical difficulty. Government in NSW is so reactive that policies often seem to be the product of a form of media management. The beleaguered DOCS embodies that approach by treating inevitable mistakes and tragedies as exceptional. "You can't get it right all the time, no system can," Moore says. "That doesn't mean they shouldn't do much better than they do."

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