Warning: This story contains details of stillbirth and neonatal death and images of a stillborn baby.
They arrived stressed but excited. They bought tiny jumpsuits, cute comforters, and snug little bonnets.
At home they had cribs and nurseries decked out in either boy or girl colours along with eager grandparents-to-be.
But instead of taking home contented gurgling infants, they ended up with silent still bundles in small white caskets.
Others took home babies with brain damage and respiratory issues from inhaling their own faeces, while the mothers themselves came home with injuries that in some cases prevented them from having more children.
An investigation by the ABC has uncovered sensational allegations by a whistleblower that dozens of expectant mothers who attended a Queensland hospital received substandard maternity care that put their babies’ lives at risk and did not follow official clinical guidelines.
In a 15-month period, one baby died and two more were stillborn at the hospital, while others were left injured after questionable care.
Some of the mothers were also left with serious complications including being unable to have more children.
The ABC can also reveal that prior to the deaths, the hospital had received multiple official risk reports and warnings about flawed care, but downgraded some of them.
Despite the litany of incidents, the public has never been told about these systemic issues at the hospital.
“It’s abysmal. It almost brings me to tears like that people come in trusting us to do the right thing and we didn’t do our job,” says Jackie Pulleine, the midwife who’s speaking out for the first time to expose the scandal.
It took a grieving mother to provide the first public hint of major problems with maternity care at Redcliffe Hospital, a busy state government medical institution servicing the rapidly expanding suburbs north of Brisbane.
First-time mother’s loss places hospital in spotlight
Meg Flaskett watched her newborn daughter Thea die in September last year.
The first-time mother had presented to the hospital several times during her pregnancy, concerned that her unborn baby wasn’t moving — a well-known indication that something could be wrong.
Despite Ms Flaskett alerting the staff to the decrease in movements of her unborn baby, she wasn’t sent for scans.
“Nobody had really checked with us,” she said.
She said despite the warning signs, she was encouraged to continue to term.
When Thea was delivered, she had the umbilical cord around her neck, Ms Flaskett said.
“She was a bluish colour and groaning.
“She remained blue and groaning for the first eight minutes of her life on my chest before anybody attempted to take her for resuscitation.
“There was an eight-minute argument between a doctor and midwife about whether she needed help.”
Then, when Thea was taken away to be resuscitated, Ms Flaskett said staff struggled to use the oxygen equipment.
Angry and grieving, she went to the media to share her story.
The hospital denied any fault with equipment or care by staff, but Health Minister Shannon Fentiman promised immediate changes to maternity care in Queensland, including increased training in neonatal resuscitation.
“These are simple changes, but they will make an enormous difference for so many families,” Ms Fentiman told parliament.
Midwife repeatedly warned of problems
What was not revealed at the time is that the baby’s death was the third at the hospital in a 15-month period.
And it had occurred despite the hospital having received repeated warnings from Ms Pulleine, a veteran midwife, about problematic care.
Ms Pulleine had been employed at the hospital for more than a decade collecting perinatal data from the maternity ward to upload to a government database, a task that involved poring over patient medical records and gave her a unique perspective of maternity care.
As a midwife with years of experience, Ms Pulleine believed she also had a responsibility to alert managers to any significant flaws or critical incidents involving the provision of care that she picked up in the medical records.
Often she would email concerns to managers pointing out certain important treatments or practices had not followed the state’s official clinical guidelines.
But if the failures were particularly serious and led to harm or were life threatening, she would file an official clinical incident report called a RiskMan and give the incident a rating of between one and four.
A one rating, the most serious, would be for a patient dying or suffering permanent injury “that was not reasonably expected as an outcome of healthcare”.
The one-rated RiskMan should then trigger an investigation by a panel of relevant clinicians.
From 2021 to 2023, Ms Pulleine alerted hospital higher-ups to dozens of cases where she thought the care had been sub-standard.
She reported cases where infants had died, suffered brain damage and required extensive resuscitation at birth after problematic care.
In some cases, she reported the mothers had been harmed as a result of the issues.
One incident in 2021 involved the hospital allegedly failing to properly monitor a mother and baby, with the baby’s heart not recorded as having been checked for over five hours.
The baby was born requiring oxygen and was later found to have hypoxic ischaemic encephalopathy – a brain injury from a lack of oxygen or blood to the brain.
Another in 2021 involved a mother who Jackie reported had her baby via caesarean and then had to have an urgent hysterectomy after severe bleeding from a cervical tear.
Ms Pulleine reported that there were no observations on the chart of this mother and that the woman had spent two hours in recovery with excessive bleeding.
Concerns were ‘brushed aside’, midwife says
As the tally of reports mounted up, Ms Pulleine started to worry they were not being taken seriously, or in some cases were being actively downplayed.
“I had a history of reporting concerns … being brushed aside and not addressed at the ground level. I didn’t feel I was being listened to,” Ms Pulleine said.
Another case Jackie reported in mid-2021 involved a mother who had given birth and suffered a haemorrhage, losing more than a litre of blood.
But for some reason a doctor had not been informed of the haemorrhage for nearly six hours, according to Ms Pulleine.
The mother, who was anaemic prior to the birth, had later required two blood transfusions while the baby was admitted to a special care nursery after inhaling its own faeces and spent 21 days in a special care nursery on oxygen.
Metro North Health was contacted about the incidents but said it was unable to comment on the cases where patients were not named. A spokesperson said that some cases mentioned were the subject of legal action and it would not be appropriate to comment in detail.
Ms Pulleine kept sending risk reports and emailing managers when she saw near misses. She said some of the RiskMans were downgraded.
Metro North says all incident SAC ratings are reviewed and at times are increased or decreased as more information becomes available.
A near-miss and a promise to do better
In mid-2022, Ms Pulleine says she went on holiday, but her job was not backfilled in her absence.
That month, 36 weeks-pregnant type-one diabetic Charmaine Janissen presented to the hospital feeling “very unwell”.
The 29-year-old already had two other children, both of whom had been delivered early at about 36 weeks by C-section.
“I was really sick and couldn’t eat anything. I’d been sleeping sitting up in bed for about three months,” she says.
Charmaine recalls feeling disorientated and barely making sense from her diabetes.
Jackie reported she went to the hospital three times within the space of three days and was sent home twice.
Charmaine said, “I was going into Ketosis, but my diabetes has been very well controlled throughout my life, so I didn’t know what was happening.”
Diabetic ketoacidosis is a potentially fatal complication of diabetes that essentially turns blood to acid. It’s extremely dangerous for both a mother and baby.
The acidity of the mother’s blood makes her body an aggressively hostile environment for a baby.
“The medical team (at the hospital) should have recognised that I was not comprehending … I was not answering their questions.”
To make things more complicated, Charmaine was diagnosed with COVID.
She says her admission only occurred after medical staff noticed she had an irregular heart rate and abnormalities.
“They worked out that I was probably about to go into a coma and the baby was getting really sick inside me … they put me straight into an emergency caesarean which I still didn’t have for a few hours,” she says.
Both Charmaine and her baby Reiv needed emergency treatment. Charmaine says she was later told Reiv had to be resuscitated for several minutes when he was born and also had to be treated for sepsis.
While they both made it home, Charmaine says Reiv still has breathing difficulties she believes relate to problems at birth and has regularly been back to hospital to treat the symptoms.
After she left the hospital with her baby, Charmaine says she later met with the hospital management to discuss her treatment.
“They just said there’s some things that could have been done better and staff needed more training,” she says.
“They said I should take comfort that this is never going to happen again … it’s not going to happen to other mums.”
What Charmaine wasn’t told was that just four weeks after her own traumatic delivery, another mother with type 1 diabetes had been admitted to the hospital to give birth, but this time the baby was stillborn.
For Lacey, anticipation turns to anger and grief
Lacey Morgan was excited, expecting her second, and was hoping for a boy.
“And then we found out early that it was a boy,” she said.
The 21-year-old knew her pregnancy would require extra monitoring because of her type 1 diabetes, but she was excited and not overly concerned.
But by 30 weeks Lacey says she was very ill with influenza and vomiting and high fevers.
“I went to the hospital the first time and ended up in a corridor because there were not enough beds,” she said.
Lacey says she felt she could take care of herself better than the hospital.
“I went home to give myself insulin,” she said.
She returned three days later and was admitted and ended up in emergency where she says they told her, the baby’s heart “wasn’t great”.
“They wanted to go see if I was contracting, but we never got that far … it never happened,” she said.
The following morning Lacey says the baby’s heart rate was still concerning staff at the hospital and because of her condition the hospital wanted to transfer her to the Royal Brisbane Women’s Hospital.
But she said she waited hours and then was told there would be no transfer.
Lacey says they gave her steroids to help her baby’s development, but she says no-one bothered to monitor him for over 24 hours.
“They told me that they had forgotten and then they got someone to check.”
She said the baby’s foetal heartbeat monitoring was again hard to read with medical staff not seeming to know if it was her own heart rate or that of her unborn baby.
Concerned and in pain, she said she asked for the baby to be born via a Caesarean, but a doctor rejected the request.
“He told me to stop whingeing, and that if my baby was born, he would be very small,” she alleges.
“After arguing for about an hour he told me he will take me for an ultrasound and if there was anything abnormal, he would take me into surgery.
“I was angry, I was begging for a Caesar.”
Lacey says during the ultrasound, the nurse put the device on her belly and there was “just nothing, a flat line” and immediately she was rushed away for a c-section.
“I woke up and I asked is my baby alive, and I just got: “No”. There was nothing.. and they passed me the baby,” she said.
To add to her misery, Lacey says with her deceased infant in her arms she was wheeled down the corridor to another room, past other mothers with their babies.
When Ms Pulleine returned from holidays she heard about Lacey’s case and then she saw Charmaine’s case that had occurred just weeks earlier.
She was very concerned about the failings in care.
What was also immensely disturbing was that no-one had bothered to file a RiskMan report to alert management to the problems that occurred in Charmaine’s case just weeks before Lacey’s.
This was despite a policy calling for “all clinical incidents actual or near miss to be reported” in the RiskMan system.
Such reports would normally trigger investigations in order to learn from the incident and prevent a recurrence.
Metro North has acknowledged to the ABC “that a RiskMan entry should have been made sooner by another clinician” in relation to Charmaine’s case.
“Ongoing training is provided to staff across Metro North Hospitals on the appropriate reporting of critical incidents,” a spokesperson said.
Ms Pulleine said she worked overtime to file a detailed report on Charmaine’s case.
She reported that staff took 13 hours to diagnose Charmaine with ketoacidosis and then nearly three hours for the treatment to commence.
She noted that Charmaine presented at the hospital several days before she was admitted, and it was known that as a type 1 diabetic she was a high risk pregnancy.
But Ms Pulleine reported there was no record of any blood sugar level or record of any urine test being undertaken during that admission.
Jackie reported when they did do tests, they were slow to respond.
“They sat on her for a little while and took her to theatre and her baby was nearly dead,” Ms Pulleine said.
“It (the baby) had inhaled its own poo and was quite unwell with pneumonia as a result of that and she (the mother) ended up in intensive care unit for two days.
“That was worrying.”
According to Jackie’s report, the baby had to be kept on oxygen for 72 hours while Charmaine spent two days in the intensive care ward.
Ms Pulleine also examined Lacey’s case and reported that while her ketoacidosis was recognised quite early, there were again problems with its management.
“It had been a massive 29-hour gap between checks on the baby’s heart,” she said.
She said there had also been a discussion with a consultant about transferring Lacey to the Royal Brisbane Women’s Hospital (RBWH).
But it was agreed there was no need for the transfer of Lacey.
As well as delays in monitoring the baby’s heart rate, and confusion about her transfer to the RBWH, Jackie reported that Lacey’s chart also recorded her as complaining of abdominal pain and that Lacey was reporting decreased movement by her baby – something that should have led to an escalation in care.
What also shocked Ms Pulleine was that after the death, the placenta went missing – something which was essential for a full investigation into what had gone wrong.
“They said they even went through the rubbish bins looking for it,” Ms Pulleine said.
Metro North Health has admitted that the loss of the placenta “should never have happened”.
A spokesperson said the health service had apologised to the patient and it was a “highly unusual occurrence and measures had been taken to ensure it would not happen again”.
Ms Pulleine decided it was time to speak out.
“I’d had enough,” she says. “I needed to escalate it because I couldn’t sleep at night anymore”.
Another baby dies in questionable circumstances
She wrote to the then-Health Minister Yvette D’ath whose electorate took in Redcliffe Hospital.
The email sent on July 23, 2022 was a whistleblower complaint raising concerns about a toxic workplace, adverse outcomes for patients and coverups.
It took several days for a response, but in the meantime an email was sent to maternity staff that acknowledged there was an issue.
“Some deviations from normal practice have occurred in our assessment and management of care of these (diabetic) women,” the email stated.
“It has been identified that a sustained clinical pathway for the care and management of pregnant women with diabetes in particular Type 1 need to be developed.”
Nearly a week later, on July 29, in response to her whistleblower complaint, Ms Pulleine was summoned to a meeting with hospital managers where she again raised her concerns. She was told they had been noted.
She left the meeting thinking something would be done. so she waited.
In August, she received an email from an investigator from Queensland Health’s Metro North ethical standards unit indicating he was looking into the matter.
But Ms Pulleine says just three months after Lacey lost her baby, another baby was stillborn at Redcliffe Hospital in questionable circumstances.
This time the mother was not diabetic but Ms Pulleine says there were other significant concerns about the level of care the mother received.
Ms Pulleine said the mother presented to hospital around September at about 34 weeks pregnant and alerted staff that her baby had reduced movements.
There were also concerns the mother had borderline high blood pressure or hypertension – a serious condition for pregnancy.
Ms Pulleine reported that the risk factors, especially the reduced movements, did not seem to trigger any formal ultrasound.
She said the mother presented again to the hospital at 39 weeks and at 40 weeks and was booked in for an induction.
There was no review by a doctor at those appointments despite the risk factors, she found.
The mother was also allowed to go weeks over term despite the risk factors.
When she presented for her induction at about 7:30pm on September 15, no initial observations appeared to have been done, Ms Pulleine said.
A doctor requested a CTG, a routine monitor of the foetal heartbeat and uterine contractions which was done about 8.30pm and was abnormal and then an emergency C-section was quickly undertaken according to the midwife’s report.
But the baby was stillborn with no signs of life and could not be resuscitated.
Meanwhile, despite the second death and Charmaine’s traumatic experience, Ms Pulleine says she heard nothing about her whistleblower complaint.
She continued alerting managers to problems.
Whistleblower’s job to be eliminated
Months passed, then in early 2023 Ms Pulleine received correspondence stating that her allegations of bullying had been unproven but concerns about the maternity care had triggered an independent on-site assessment of the services at Redcliffe Hospital in January 2023.
“I wish to inform you that during the MNHHS Integrity Unit Investigation systemic issues were identified in Maternity Services, Redcliffe Hospital,” said executive director of Redcliffe Hospital Louise Oriti.
Ms Oriti stated she had decided to engage an outside company to undertake an assessment of maternity services at the hospital and there would also be “an assessment of the quality/safety systems, organisational structure and workforce”.
An independent senior midwifery leader was appointed to lead the review and the findings and recommendations were handed to the hospital executive in March 2023.
A clinical assessment was supposed to have been undertaken and resulted in a senior midwife appointed to project manage the implementation of recommendations to “modernise models of care”.
As far as Ms Pulleine was concerned, all the reviews and investigations had only led to the appointment of another manager – not more trained staff and resources.
In May 2023, Ms Pulleine says she was called in and told her job collecting perinatal data would cease to exist towards the end of the year and that she would be assigned to another role.
Metro North Health says the job of entering perinatal statistics had ceased to exist as a result of the hospital migrating from a paper-based medical record system and data capture for perinatal statistics will be captured in real time.
Despite the impending end of her role, she said she kept alerting her managers to her concerns.
Then Meg Flaskett’s baby Thea died just shortly after being born at the hospital — the incident that prompted the state government’s promise that critical changes were going to be made.
Ms Pulleine says she was not working at the hospital in the aftermath of the loss of Thea in September last year, but she has grave concerns about the level of care Meg received.
She said Meg had presented several times to the hospital with reduced movements of the baby but only seemed to have had one ultrasound.
Ms Pulleine also believed that Meg was not observed appropriately and her induction was delayed.
“It was a weekend and there were five women in labour, high acuity in the ward and she (Meg) was allocated to a junior practitioner,” said Ms Pulleine.
A Metro North spokesperson said a clinical review had been completed of Ms Flaskett’s case and found no evidence that staff could not operate the equipment which was not faulty.
The spokesperson confirmed the replacement of an oxygen tank but said staff were trained to replace the tanks.
“Recommendations including Ms Flaskett’s feedback are in the implementation process,” the spokesperson said.
The case is currently being reviewed by the Coroner’s Court of Queensland.
Health Minister Ms Fentiman told ABC Investigations she had previously met with Ms Pulleine to hear and address her concerns.
She said an external review had been carried out to address all issues raised by Ms Pulleine and the hospital and health service had made significant improvements.
Ms Fentiman said she wanted to “acknowledge Meg and the mothers who have shown incredible bravery sharing their stories”.
“I take any concerns raised, by patients or staff, about care provided within our health system very seriously,” she said.
The medical director for Redcliffe Hospital’s critical care women and children’s service line Kim Hansen said the assessment had led to an external expert being brought in to examine all aspects of maternity services and had made 37 recommendations.
Dr Hansen said the hospital had implemented 23 “with work progressing on those remaining”.
The hospital had re-commissioned the external expert to return to Redcliffe in April this year to undertake a follow-up which reported “good progress has been made”.
She said the Metro North Hospital had made significant improvements to its patient care, to ensure its maternity service was safe and reliable, so that expectant mothers got the best care possible.
Improvements had included additional staffing in some maternity service priority areas and the hospital’s antenatal day assessment service had been expanded to provide a seven-day service, she said.
Dr Hansen said there had also been an additional allocation of midwives to ensure all women had the support of a midwife in the Post Anaesthetic Care Unit for skin-to-skin contact with their baby following a caesarean section and a diabetic educator and a senior midwifery director had been added to the service.
She said the hospital worked closely with parents who had lost babies in their care to ensure they got the support they needed.
“The death of a baby in childbirth is traumatic and our deepest sympathies go to anyone who has experienced such a devastating loss,” she said.
Former Health Minister Ms D’ath said her office alerted Queensland Health to Ms Pulleine’s whistleblower complaint.
She said Queensland Health referred the complaint to the Ethical Standards Unit and committed to a review.
For mothers like Charmaine, Lacey and Meg, revelations that Ms Pulleine had been battling to raise standards is shocking but has also left them with more disturbing questions.
On a balmy autumn morning at bayside park near Redcliffe last month, the ABC arranged for Ms Pulleine to meet for the first time with Lacey and her partner Severio Rochford.
The couple peppered the veteran midwife with questions and while they were reassured that the baby’s loss was not their fault, Ms Pulleine’s responses reinforced their concern about the care they received.
One question in particular had been haunting Severio.
“Did he suffer before he died,” he asked about Remy, his stillborn son.
Ms Pulleine answered slowly, confirming the child would have been in distress.
Severio broke down and turned away, covering his face with his hands.
Posted , updated