Tribunal reprimands medical practitioner for obstetric care at Bacchus Marsh Hospital

04 Feb 2022

A medical practitioner working in obstetrics at the Bacchus Marsh Hospital has been reprimanded by the Victorian Civil and Administrative Tribunal (the tribunal).

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The tribunal ordered that Dr Jocelyn Benedicto be reprimanded after findings of professional misconduct and unprofessional conduct. Dr Benedicto was employed as a career medical officer (obstetrics and general) at the Bacchus Marsh Hospital (operated by Djerriwarrh Health Services) between 2008 and 2015, when there was a tragic cluster of newborn and stillborn deaths.

The Medical Board of Australia (the Board) referred Dr Benedicto to the tribunal in June 2018 for professional misconduct. The 16 allegations against Dr Benedicto related to her obstetric care of eight patients who delivered their babies at Bacchus Marsh Hospital between February 2008 and September 2015.

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

The Board’s allegations against Dr Benedicto concerned her:

• deficiencies in cardiotocography (CTG)interpretation
• failure to arrange an emergency caesarean section before attempting a forceps delivery
• applying traction with forceps an unacceptable number of times
• failure to work within the limits of her competence or supervision
• failure to develop a suitable management and/or treatment plan for placental abruption, and
• record-keeping deficiencies.

The tribunal found all 16 allegations were proven and that Dr Benedicto had engaged in professional misconduct and unprofessional conduct. The tribunal ordered that she be reprimanded. The Board had submitted that, in addition to a reprimand, Dr Benedicto’s registration should be suspended for three months.

The Tribunal noted that there were mitigating factors in this matter, including that:

• Dr Parhar’s supervision of Dr Benedicto was ‘undoubtedly inadequate’
• the last allegation relating to the conduct happened in 2015 with no further incidents reported
• Dr Benedicto had since carried out extensive education/training and improved her skills, and
• she had displayed insight.

Dr Benedicto continues to work for Djerriwarrh Health Services and currently holds the role of senior resident in obstetrics. 

The tribunal agreed that a three-month suspension of Dr Benedicto’s registration would have been appropriate. However, it was concerned about the evidence given on behalf of Dr Benedicto that suspending her would endanger the safety of the maternity service at Bacchus Marsh Hospital.

‘… we have refrained from imposing a suspension, only because we do not want a decision of this tribunal to have a potentially catastrophic impact on the safety and continuity of the care of the current maternity patients …’

The tribunal regarded a suspension appropriate in the interests of general deterrence and to protect the reputation of and confidence in the profession, not because it considered that Dr Benedicto is currently an unsafe or incompetent medical practitioner.

The tribunal supported the Board’s submission that being let down by her supervisor and working in an environment where poor practices were normalised did not absolve Dr Benedicto from her own responsibility to ensure that her practice was safe and consistent with professional standards.

‘… each and every practitioner bears personal responsibility for ensuring that they are able to practise in a safe manner and within the limits of their competence.’

The full tribunal decision is published on the AustLII website.

Background

In October 2015, Ahpra and the 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 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 Administrative Tribunal.

For more information

• For media enquiries, phone (03) 8708 9200.
• For registration enquiries, please phone 1300 419 495 (within Australia) +61 3 9285 3010 (overseas callers).
• To make a notification, visit here or call 1300 419 495.