In 2013 and 2014, seven babies suffered avoidable deaths at Bacchus Marsh Hospital. Subsequent review exposed serious deficiencies in both care and clinical governance at the hospital, with the responsible health service (Djerriwarrh) failing to respond appropriately to a number of serious safety breaches and complaints about the hospital. For further information, see Maternity services at Djerriwarrh Health Services

At the request of the Minister for Health, the Department of Health and Human Services has commissioned a review to examine ways to strengthen the approach to governance of safety and quality in Victorian hospitals. The review will provide advice about quality and safety systems and, where they are not adequate, how they might be improved to achieve best practice.

Review panel

The panel consists of:

  • Dr Stephen Duckett, Director, Health Program, Grattan Institute (chair)
  • Ms Maree Cuddihy, Chief Executive Officer, Kyneton District Health Service
  • Associate Professor Harvey Newnham, Clinical Program Director of Emergency and Acute Medicine, Director of General Medicine, Alfred Health.


The review panel will make recommendations that, once implemented, will assure the community that system and hospital governance arrangements are in place to foster safe and high quality health services, with opportunities for improvement promptly identified and acted upon.


The following activities will be undertaken by the review panel.

  • Consultations with key stakeholder groups throughout March 2016.
  • An all day workshop for regional and rural health services in March 2016.
  • A discussion paper will be released in March and provide an opportunity for public comment. The paper will discuss themes related to:
    • fostering continuous improvement and clinical excellence
    • improving hospital governance
    • strengthening oversight of safety and clinical governance
    • advancing transparency 
  • Review of all public submissions received.
  • Final report

Discussion paper

The review panel invites the sector and community to reflect on the issues raised in this discussion paper and to contribute their feedback and ideas for a safer hospital system. 

Comments and submissions should be sent to qualitysafetyreview@dhhs.vic.gov.au by 8 April 2016.


For further information contact us via email: qualitysafetyreview@dhhs.vic.gov.au