A doctor who was director of obstetrics and gynaecology at a Victorian hospital during a cluster of baby deaths has been effectively banned from practising medicine again. However, the disciplinary action has come years after he already retired.
Dr Surinder Parhar has not practised medicine since October 2015, after an investigation into a tragic cluster of newborn and stillborn deaths at the Bacchus Marsh hospital. He worked at the hospital for 30 years.
The Victorian Civil and Administrative Tribunal made nine findings of professional misconduct against Parhar, banning him from practising for another 12 years. While it was not alleged Parhar directly caused any of the deaths, the tribunal found in its decision published on Wednesday that he “failed to recognise that what was happening needed to be addressed, and that he had individual responsibility to do something”.
The case concerned Parhar’s actions related to 27 maternity patients at the hospital between 2008 and 2015. Twenty-one of those patients experienced stillbirth or death of their baby shortly after birth, while others experienced various adverse events, a rate much higher than what would be expected for a hospital of the size of Bacchus Marsh.
“As a low-risk birthing facility, the number of adverse outcomes over a short period of time should have led to ‘alarm bells ringing’ but did not,” the tribunal found. “Little action was taken to identify the causes of the adverse outcomes or implement changes in practice. The failures in practice were not identified and continued for a significant period of time putting more patients at risk.”
The tribunal found deficiencies in Parhar’s direct clinical care of one patient after he failed to recognise her symptoms were the result of the death of her baby. He also failed to ensure there were adequate clinical reviews of 19 perinatal deaths; to ensure there was adequate open disclosure with patients in relation to 15 perinatal deaths; to ensure necessary policies were in place to improve patient safety; to provide adequate supervision of three junior doctors; to improve or maintain his own professional performance; or to keep proper records.
Parhar admitted to all of the allegations.
“He is highly remorseful – he is sorry for himself and his role in this ‘sad story’ but also sorry for the impact on the parents and the community,” the decision said. “He recognises that his career has ended in shame and ignominy. Much of what has been identified is very much ‘with the benefit of hindsight’.”
The tribunal decision said Parhar was not the only staff member to fail patients, noting “an almost systemic complacency and misguided self-congratulation about the quality of the maternity service”.
Other cases involving former hospital staff at the time are due to come before the tribunal. But the tribunal found there had been “years of missed opportunities to recognise and acknowledge what was going wrong, and act to prevent future avoidable deaths and adverse patient outcomes”.
“Parhar was not the only senior health practitioner … to be blind to the pattern emerging and to fail to recognise that alarm bells should have been ringing,” the decision said.
“Nevertheless, he occupied a significant leadership role as the director of obstetrics, although he did not apparently recognise that;and he had undoubted responsibilities as a medical practitioner and senior obstetrician, which he did not properly discharge.”
The tribunal acknowledged that its decision to ban Parhar from practising medicine for 12 years would have little practical impact on his career given he was already retired.
“But it sends a clear message to those who may still expect to have years of medical practice before them that, if they engage in similar conduct, their time as a doctor is likely to end well before their planned retirement,” the decision said.
In 2015, the Australian Health Practitioner Regulation Agency (Ahpra) apologised for the length of the investigation into the health service, after first receiving a complaint in 2013 about the care a different doctor provided to a mother after a stillbirth. Ahpra has investigated 43 health practitioners who then worked at Bacchus Marsh hospital.
On Wednesday Ahpra chief executive, Martin Fletcher, said this tribunal decision was a strong outcome in response to “tragic and sad events”.
“It is important to hold accountable practitioners in leadership roles who have clear responsibilities for patient safety and who fail to act,” he said.
The case against Parhar was brought by the Medical Board of Australia. The board’s chair, Dr Anne Tonkin, described the failures of the hospital as “tragic”.
“While we recognise this decision may be of little comfort for the families who so sadly lost their babies, it highlights the importance of registered medical practitioners, especially those in senior positions, understanding and acting on their responsibilities to ensure safe patient care,” she said.