Formerly registered medical practitioner working in obstetrics at Bacchus Marsh reprimanded and disqualified for three months

19 Jan 2022

The Victorian Civil and Administrative Tribunal (the tribunal) has reprimanded a formerly registered medical practitioner working at the Bacchus Marsh Hospital and disqualified her from applying for registration for three months.

Trigger warning: Some readers may find this article distressing. If you are experiencing distress and are a registered medical practitioner or medical student, please visit the drs4drs website for support in your state or territory. Any readers can contact Lifeline on 13 11 14 for help.

Dr Lorraine Lines was employed as a career medical officer (obstetrics and general) at the Bacchus Marsh Hospital (operated by Djerriwarrh Health Services), between 2013 and 2015, when there was a tragic cluster of newborn and stillborn deaths.

The Medical Board of Australia (the Board) referred Dr Lines to the tribunal in July 2018 for professional misconduct. The allegations brought by the Board against Dr Lines relate to three of seven perinatal deaths which were found by Professor Euan Wallace to have been avoidable in his 2015 report into Djerriwarrh Health Services.

In referring Dr Lines to the tribunal, the Board alleged that she had failed to:

• take heed of the implications of pre-eclampsia
• examine, or correctly interpret, a CTG trace
• refer a patient for further evaluation
• expedite delivery of a patient’s baby, and
• attend in person to review a patient after being told by midwifery staff of that patient’s presentation of elevated blood pressure, abnormal CTG trace and urine analysis that showed a trace of protein.

The Board also alleged that there were deficiencies in Dr Line’s record keeping and that she had attempted an instrumental vaginal delivery when she had not discussed the plan with a consultant obstetrician or ensured that personnel skilled in neonatal resuscitation were present.

At the time, Dr Lines was supposed to be supervised by Dr Parhar. However, it was found that Dr Parhar had failed to provide appropriate supervision to Dr Lines and other junior doctors for whom he acted as supervisor.

In reaching its decision, the tribunal noted that it should have been ‘obvious to Dr Lines in 2013 that it was unsafe for her to be the obstetrician on duty or on call when she did not have ready or reliable access to consult with Dr Parhar or another experienced obstetrician'.

The tribunal accepted the Board’s submission that ‘being registered as a doctor is a “privileged position”, but comes with responsibility in the sense that each and every practitioner “must ensure they are able to and are practising in a safe manner”’.

The tribunal found all seven allegations proven and that Dr Lines had engaged in professional misconduct and unprofessional conduct.

In making its determination the tribunal considered several mitigating factors including the systemic issues at Djerriwarrh Health Services, the deficiencies in supervision provided to Dr Lines, the insight shown by Dr Lines, and the fact that Dr Lines continued to practise without further incident for a number of years following the relevant events.

The tribunal reprimanded Dr Lines and disqualified her from applying for registration for three months. The tribunal observed that ‘but for the substantial mitigating factors in this case, a lengthy period of disqualification might be required to send the appropriate message to the medical profession’.

Dr Lines was unregistered at the time of the tribunal’s decision, having allowed her registration to lapse on 1 October 2019. The tribunal therefore did not have the option of ordering suspension or cancellation of Dr Lines’ registration.

The full tribunal decision is published on AustLII website.

Background

In October 2015, Ahpra and National Boards launched investigations into 101 matters about the care provided by individual practitioners at the Bacchus Marsh Hospital (operated by Djerriwarrh Health Services) during the period 2008 to 2015. This followed a cluster of potentially preventable stillbirths and neonatal deaths at the Bacchus Marsh Hospital.

A total of 43 registered health practitioners were the subject of concerns in the 101 matters reported (some practitioners were the subject of multiple notifications). All investigations are finalised, with some practitioners awaiting hearing in the Victorian Civil and Administrative Tribunal.

For the 43 registered health practitioners reported, almost half (21 practitioners) had matters which were able to be closed without the need for regulatory action. This included practitioners who had surrendered their registration, or who had taken remedial steps in respect of low risk performance issues. In those circumstances, the National Boards were satisfied the relevant practitioners posed no ongoing risk to the public.

For those practitioners where further action was taken:

• six practitioners were cautioned
• six practitioners had conditions imposed on their registration (some of those who had conditions imposed were also cautioned), and
• 10 practitioners were referred to a panel hearing or the Victorian Civil and Administrative Tribunal.

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