On this page

    Please do not use this tool unless you have completed the following Fundamentals of Adverse Patient Safety Event Review modules: 
      • Human factors and Systems thinking
      • Bias, Human error, Safety culture and Just culture
      • Fundamentals of Adverse Patient Safety Event Review
      • Maternal and Child Health (MCH) Systems – Focused Review (Online Training) 

    About the review tool

    The Maternal and Child Health (MCH) Systems focused review tool provides MCH services with a systematic approach to client case reviews.

    MCH services can perform a systematic review of the care they provide when:

    • an adverse event such as unexpected death or event of serious harm has occurred; and
    • the child, mother, or family member is a current client of the Maternal and Child Health (MCH) service.

    These adverse events can include:

    • sudden unexpected infant death (SUDI)
    • sleeping accidents
    • bruising on an immobile infant
    • malnutrition (infant/child)
    • child death or infanticide 
    • child known to child protection services
    • maternal self-harm or suicide/filicide
    • family violence.

    The tool should not be used for:

    • vaccination reactions (for example, anaphylaxis)
    • minor injuries/accidents
    • motor vehicle/transport accidents
    • pre-existing medical conditions, for example, cancer, cardiac causes
    • any concerns about professional performance or behaviour, this is managed through existing organisational processes.

    Download the review tool and guidance >

    CCOPMM reports

    The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) may request records from the MCH service, inclusive of any internal reviews of the care provided to the child, mother, and/or family involved in an adverse event or unexpected deaths.

    MCH services may prepare any internal review where there has been an unexpected death or serious harm as a CCOPMM report. Documents created for the sole purpose of providing information to CCOPMM are protected from being produced to courts or tribunals, and the Freedom of Information Act 1982 and Health Records Act 2001 do not apply. When information is prepared for CCOPMM by the MCH service, it should be clearly identified as being prepared for that purpose so that documents will be protected and not admissible in legal proceedings.

    There are implications of using the tool outside of preparing a report for CCOPMM, as the protections for information provided to CCOPMM will not apply.

    In addition, the legal protections under the Health Services Act will not apply if your MCH service is operated by local government or an Aboriginal Community Controlled Health Organisation.

    More information for

    If your MCH service is operated by an Aboriginal Community Controlled Health Organisation, please do not use this tool before checking with your CEO/insurer/legal advisor. They may wish to consider whether the unexpected death or adverse harm may result in: 

    • a compensation claim against the MCH service/organisation, for example, if there is potential that a claim may be made alleging that the MCH service/organisation has been negligent; or
    • a coronial investigation or inquest, where there is potential for a finding or recommendation being made in relation to the MCH service/organisation. 

    The review tool is designed to identify improvement opportunities in MCH systems and processes. It does not replace existing incident reporting for workplace clinical and occupational health and safety incidents. 

    If your MCH service is operated by a Public Health Service such as a hospital and is governed by the Health Services Act 1988, the quality and safety reforms may apply to your organisation. Amendments to the Health Services Act 1988 (Act) introduced protections for some adverse event reviews. Division 8 of Part 5A of the Act provides protections for the review process, including any documents or reports created as part of the SAPSE review.

    There are also relevant protections for SAPSE review panel members and participants of the SAPSE review. For more information on SAPSE reviews, see the Statutory Duty of Candour and protections for SAPSE reviews 

    If your MCH service is operated by local government please check with your insurer or legal advisor before using this tool (for those insured by MAV insurance, contact DL_insurance@mav.asn.au). They may wish to consider whether the unexpected death or adverse harm may result in:

    • a compensation claim against the council, for example, if there is potential that a claim may be made alleging that the MCH service/council has been negligent; or
    • a coronial investigation or inquest, where there is potential for a finding or recommendation being made in relation to the MCH service/council. 

    The review tool is designed to identify improvement opportunities in MCH systems and processes. It does not replace existing incident reporting for workplace clinical and occupational health and safety incidents. 

    [ Back to top ]

    Downloads

    Was this content helpful to you?
    [ Back to top ]