As an important step, an independent investigation into Alana Starkie’s care during her established labor at King Edward Memorial Hospital (KEMH) found shocking failures. These deficiencies were contributory in the unfortunate death of her newborn son Tommy. What should have been a routine planned induction in August turned tragic. Unfortunately, Tommy experienced catastrophic oxygen deprivation at birth and passed away tragically just 23 days later.
The inquiry’s investigation revealed that while in labour, Alana Starkie was in great distress and indicated deep concern for the health of her baby. Her cries for an emergency caesarean were avoided by the medical personnel, who misunderstood her request. Alana described the labour as excruciating, stating, “I have never experienced pain like that before, even with three previous deliveries with no pain relief.”
Multiple Failures Identified
The tragedy exposed major shortcomings in the local and state oversight of the monitoring and care provided to Alana and Tommy. Critically, it showed that basic checking of baby’s heart rate was frequently not done or recorded as mandated. This indifference played a part in undermining staff’s situational awareness of Tommy’s urgent state.
Our investigation found this was an alarming judgement call by the service. Despite evidence that the fetus was in distress, they doubled the amount of oxytocin given to Alana—a medication used to induce labor. Things took a catastrophic turn when Alana experienced a posterior uterine tear during a rapid labour process that made her delivery even more precarious.
The panel found that human factors, particularly communication failure and workload management, greatly prevented the staff from delivering high-quality care. In doing so, they found eight contributing system factors that resulted in these tragic outcomes.
Apologies and Future Recommendations
Robert Toms, a representative from KEMH expressed his heartfelt apologies to Alana Starkie and her loved ones. Of his deep disappointment in the findings, he said. He admitted the hospital’s failures but focused more on the need for systemic changes to ensure that the hospital wouldn’t make similar mistakes in the future.
“To Mrs Starkie and family, we again extend our heartfelt apologies,” – Robert Toms
The review generated eight lively recommendations. These recommendations center on standardizing hospital systems and increasing communication between staff during adverse events. The recommendations are intended to make these training programs stronger. In addition, they will develop and implement clearer guidelines for assessing patient needs and maintaining objective measures for monitoring high-risk patients in labor.
Implications for Patient Care
The case has highlighted important issues regarding the safety of patients as well as a culture of indiscriminate blame-shifting among medical practitioners operating in high-stakes working conditions. Alana Starkie’s experience is a powerful reminder of the need to listen to patient concerns and to validate their requests during labour. It led staffers to view challenges women faced in labor as “routine.” Unfortunately, this perception may have contributed to the delay in taking urgent action on Alana’s behalf.
KEMH is now preparing to implement the recommendations from the review. It faces the challenge of more urgently restoring trust with patients while making sure that such an unimaginable tragedy occurs never again. The investigation serves as a sobering reminder of the critical need for vigilant monitoring and compassionate care during one of life’s most vulnerable moments.
