Sorry health bosses promise change after Tommy Starkie’s death but grieving families warn it’s happened before

The grieving mother of a baby boy who died after a bungled delivery at King Edward Memorial Hospital hopes a damning report into his death will be the impetus for change. Tommy Starkie suffered severe oxygen deprivation during his delivery and was born limp. He died 23 days later. On Friday, his mother Alana Starkie said Tommy wasn’t the first victim of “systemic failure” at Perth’s major maternity hospital. “It’s a bit of a bitter pill to swallow, because people within the leadership of that (hospital) have let that culture slip,” she said. “They let it get to a point where they were failing so badly that our son had to die to bring about that, that’s not easy to accept.” A WA Health investigation has confirmed that poor communication, workload management and situational awareness contributed to Tommy’s death. Heart-rate monitoring of the baby, which was required every half-hour, was not completed or recorded, the external panel’s investigation found. The report made eight recommendations, including establishing a review of acute maternity care staffing and fetal monitoring systems, and a cultural reform program to enhance emergency responses “to ensure appropriate and timely escalations”. Ms Starkie said she was relieved, and grateful, the investigation had allowed the truth to came out. “The recommendations are good. . . (but) am I confident that they are going to fix all of the problems? No,” she said. WA Health director-general Shirley Bowen has publicly apologised to the family and confirmed she will issue an improvement notice to KEMH to launch a cultural reform and ensure an extra obstetric consultant is rostered. “We have let the Starkie family down, and for that, we are deeply sorry,” she said. “I’d like to reassure the community that babies are born safely at King Edward Memorial Hospital every day. “We are committed to learning from this terrible incident.” North Metropolitan Health chief Robert Toms said safe and high-quality care was the hospital’s “absolute” priority. “We will be ensuring all the recommendations identified by the investigation are implemented,” he said. But the Opposition said it was not the first time hospital protocols have been ignored with deadly consequences. The West Australian recently revealed another grieving mother, Immi Walker, had pleaded for an inquiry after her seven-day-old son Asher’s death at KEMH . Asher had a “catastrophic” loss of oxygen during his delivery. His family were forced to wait for three years for a coroner’s report into the circumstances of Asher’s death, due to a record backlog in the coroner’s office and local pathology services. A root cause analysis into his death in 2020 found clinical guidelines were not followed. “These are not isolated issues and they are the predictable outcome of almost a decade of neglect and under resourcing,” Shadow Health Minister Libby Mettam said. “It is unacceptable that in a major WA maternity service, a catastrophic obstetric emergency could unfold without guaranteed senior specialist availability. “The report (into Tommy Starkie’s death) details missed opportunities for escalation, fragmented communication, gaps in monitoring and documentation, and delayed intervention — all occurring in the context of high unit activity, staffing pressure and workload strain. “These are matters entirely within the Government’s control.” Ms Starkie and Ms Walker are now united in grief and determined to fight together to ensure a promised overhaul happens quickly. “Policies are useless if they’re not followed,” Ms Starkie said. “We can’t believe that this has happened twice at the same hospital and still the culture is where it is, that it failed us both so badly. “We’re completely united in our push to get these changes made so that the hospital is a safer place for mums and babies and this doesn’t happen again, and no one has to go through the trauma that Immi and I have experienced.” Deputy Premier Rita Saffioti said she was “very, very surprised” by the extent of the failings in baby Tommy’s case. “As I understand, this was not a matter of funding, but we stand prepared to continue to invest in our health system,” she said. “Our sympathies go out to the family on what is a tragic, tragic event. “In relation to the inquiry that’s been held and the report, I understand the Director-General will be implementing the full recommendations as soon as possible to ensure that any issues that were highlighted, or any failures, are addressed.”