St John of God Bunbury Hospital review: WA parents say fatal bungle ‘must be the last’ as findings delivered

A review of maternity services at a private Bunbury hospital where a baby boy was stillborn after staff nearly killed his mother with a massive morphine overdose has called for improvements to education and staffing. St John of God Bunbury Hospital requested the external review after Sunny Alam and Sarah Hassan lost their son Zyeen when staff injected Ms Hassan with 100mg of morphine — 10 times the amount prescribed — and then failed to check on her overnight when she went there to give birth in December. The Bunbury couple, who have since moved to Perth to be closer to family, said they hoped the reviews prompted by their baby’s death would lead to positive changes and stop anyone else from suffering the same pain. “All we want is that this will never happen again,” Mr Alam said. The review noted SJOG Bunbury had undergone “significant executive change” in recent years and was experiencing midwife shortages similar to workforce pressure in other WA hospitals. Despite recommending a raft of changes to improve services for mothers and babies, the reviewers did not uncover any other problems. “Apart from the sentinel event that triggered the review, the obstetric and neonatal outcomes for the service compare favourably with equivalent services and the reviewers did not find any other evidence of concerning substandard practices,” the report stated. Recommendations included rostering only midwives in the maternity unit at night instead of bolstering their numbers with nurses, improving professional learning for staff and partnering with Bunbury Regional Hospital next door to share a nursery across both of the campuses. SJOG Bunbury chief executive Jeffrey Williams said the hospital recognised the need to rebuild trust and did not play down the “devastating” effects of the medication error. “We will never be able to replace Sunny and Sarah’s little boy,” he said. “Our focus has been on ensuring this can’t happen again to another family.” Mr Williams said it was challenging to recruit enough midwives. “Notwithstanding, on the night that incident occurred, that unit was fully and properly staffed,” he said. The hospital had already made changes identified by its own review. These included revising medication inventory management, extra training and updating handover protocols.