THE death of baby Caitlin Porter at Ipswich seven years ago should have sparked an immediate hospital review into what went wrong.
The fact that it didn't happen has brought about a stinging rebuke by the Minister for Health's office, which has now confirmed a review is underway.
The office said Caitlin's mother taking her complaint to the newly-created Office of the Health Ombudsman had brought about the review.
Mum Rachelle Lind is due to meet with Ipswich Hospital management and the Health Ombudsman today.
As reported in yesterday's QT, a damning report from the Coroner listed a series of mistakes following Caitlin's birth and noted a lack of paediatric experience from the Ipswich Hospital health officer responsible for Caitlin.
The Coroner's report, handed down on September 5, 2012, also referred the paediatric specialist involved to the Australian Health Practitioner Regulation Agency (AHPRA) for consideration of disciplinary action.
The paediatric specialist, who continues to practice in Ipswich, did not return calls from The QT yesterday.
Even though AHPRA has had the coroner's report for two years they have still to conclude their investigation and yesterday offered no reasons why.
The State Coroner took five years to complete his report into the death and sought independent opinions from two doctors on the events that lead to Caitlin's life support to be turned off 10 hours and 40 minutes after she was born.
During that time the Coroner says treating staff at Ipswich Hospital failed to initially appreciate the seriousness of Caitlin's condition, resuscitation attempts were inadequate, an endotracheal tube was wrongly positioned prolonging the inadequate resuscitation.
Ttests ordered by the paediatric specialist at 3.30am were not done, the doctor was asked to attend at 6.15am and did not arrive until 6.50am, he did not pick up on the wrongly placed tube which was evident in two X-rays and a huge haemorrhage to the back of the head was not identified by the treating team at Ipswich Hospital.
A spokesman for Queensland Health Minister Lawrence Springborg said a full root cause analysis (RCA) should have been carried out after the death in 2007 and there was no evidence of that taking place.
"It is not good enough that there was no immediate RCA," he said.
"Those sorts of things are just unforgivable."
"A delay of that time is precisely the complaint that led to our decision to sack the Queensland Board of the Medical Board of Australia, removed AHPRA from key areas of responsibility in the administration of health complaints and we have established an independent Health Ombudsman.
"Sixty per cent of the complaints to AHPRA were not being acted on in a timely or appropriate way.
"It was dysfunctional.
"It was not good enough."