A cluster of baby deaths at a Bacchus Marsh hospital has triggered sweeping changes to how Victoria will manage medical errors and patient safety across the state.
A damning independent report has found that for many years the state health department left patient safety in the hands of individual boards, creating gaping holes in monitoring and a culture of cover-up and missed opportunity.
The findings of the review into hospital safety, led by health services expert Stephen Duckett, will be made public on Friday and have already sparked what the government is calling the biggest shake-up of the health system in decades.
Health Minister Jill Hennessy will reveal a new hospital safety watchdog called Safer Care Victoria, to be headed by leading obstetrician Professor Euan Wallace, which will take charge of monitoring patient safety and include the state's chief medical, nursing, paramedic and allied health officers.
The government will also create the Victorian Clinical Council to advise it and health services on how to make hospitals safer, and also launch a new health information agency to overhaul how health performance data is collected and ensure it is reported publicly.
A Ministerial Board Advisory Committee will be launched to oversee hospital and health service boards.
The changes are a response to dozens of recommendations made on the back of the Duckett review, all of which the government has accepted in principle, including bolstering appointment processes for hospital boards, which must include clinicians and consumer representatives.
"The reforms that we're putting in place mean that there will never be just one body that monitors quality and safety," Ms Hennessy said.
"One of the many lessons from Djerriwarrh is that you need many eyes and many checks and balances in place to ensure that catastrophic failure in the health system is not able to ever be ignored or covered up."
The department had not only failed to detect the spike in potentially preventable baby deaths at the Djerriwarrh Health Services' Bacchus Marsh Hospital in recent years, but had been failing to oversee hospital safety generally for more than a decade, a failure that had been flagged in at least three official reports, the review noted.
Another investigation, specifically into what happened at Bacchus Marsh and conducted by Professor Wallace, recently found 11 deaths dating back to 2001 may have been avoidable and the health service had failed to monitor adverse clinical events.
Ms Hennessy said the changes meant health safety and quality would be taken out of "the darkness of bureaucracy", put into the hands of clinicians and patients, and opened up to public scrutiny "so we're able to respond to poor performance in real time".
Audrey Ann Prior, now aged three, was not breathing when she was born with the umbilical cord wrapped around her neck on March 19, 2013, at Bacchus Marsh Hospital.
After being resuscitated, the baby girl suffered seizures, causing her to be rushed to the Royal Women's Hospital, where she was diagnosed with cerebral palsy and hypoxic ischaemic encephalopathy – brain damage caused by oxygen loss.
Audrey's parents, Melissa and David Prior, hope the reforms will save other families suffering as they did three years ago.
"What happened to our family at Bacchus Marsh Hospital was unforgiveable," the couple said.
"Knowing that this could have potentially been avoided is very distressing, and for a long time we have been seeking answers for what happened to our daughter.
"Our wish, however, has always been that something may come of this so that no other family ever has to go through what we have been through. We hope that greater oversight of incidents will make sure that is the case."
Maurice Blackburn Lawyers is acting for more than 20 families, including the Priors, allegedly affected by failings at Bacchus Marsh Hospital.
"Nothing will ever undo the pain so many of our clients feel having lost babies in avoidable circumstances, many of whom have had to wait over 20 years for proper answers. A watchdog with greater oversight and scrutiny to help prevent such events in future is welcome," the firm's head of medical negligence, Kathryn Booth, said.
"In our view, bureaucracy was a key factor in these events, and it is crucial that in addressing the issues uncovered that any solutions focus on justice for those affected, and not further bureaucracy."
Ms Hennessy said other reforms, including the possibility of no-fault medical insurance for healthcare injuries, like that seen with workplace incidents, and a potential "duty of candour" law, would encourage reporting and ensure doctors can be more open with their patients when things go wrong. "Not only does the patient suffer, the healthcare system never gets to learn from those errors," she said.
Safer Care Victoria and the new data agency are expected to be up and running by January. A Safety and Quality Bill would be introduced to Parliament next year to address other recommendations, with a major review of the Health Service and Ambulance Service Acts to follow, the minister said.
Dr Duckett said he "couldn't have been happier" with the government's response to the recommendations. "What we saw was the department relied very heavily on boards and systems to get things right and the weakenss of that was the department didn't give enough support to health services," he said.
"There wasn't enough accountability for what the health services were doing."
When asked if these changes would guarantee detection of a spike in baby deaths in the future, Dr Duckett said: "I can't guarantee that it will always be found, but what we're trying to do is increase the likelihood that it will be found."
Department of Health and Human Services secretary Kym Peak released a statement saying the department was addressing the recommendations and welcomed changes.
"We're committed to providing greater oversight and stronger leadership, working with our hospital boards, our clinicians , and with out healthcare workforce," she said.