Bungled medical treatment at a rural Victorian hospital may have led to the deaths of three newborns, the state coroner has found.
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The children's care was mishandled in near-identical ways at the Bacchus Marsh and Melton Regional Hospital and all three died soon after birth.
On Wednesday the state coroner handed down damning findings about the hospital's treatment of the newborns.
Hospital management admit "the deaths of the babies might have been prevented".
Bacchus Marsh has been under fire since a cluster of stillborn and newborn deaths was discovered by the Victoria's Consultative Council of Obstetric and Paediatric Mortality and Morbidity in 2015.
The coroner does not have the power to investigate stillbirths but looked at the death of three infants who were under the care of the hospital's maternity ward in 2013.
Coroner Jacqui Hawkins found problems with the CTG scans in all three cases.
The scans, which track a baby's heartbeat and uterine contractions during birth, are a crucial way of assessing the health of mother and child.
The scans were of poor quality, and it wasn't possible to interpret them possibly.
Even after the children had died, in two out of three cases the hospital's own internal investigation found no problems with their care.
The law firm Maurice Blackburn has been representing a number of families who lost children under the care of Bacchus Marsh, and in several cases have won settlements from the hospital.
"It is very telling, isn't it, that the hospital's own internal review processes did not spot any issues in the handling of these three cases," Maurice Blackburn medical negligence principal Dimitra Dubrow said.
In a submission to the coroner, Bacchus Marsh Hospital said it now believed that if medical care had been of an appropriate standard, the babies may not have died.
"In all three cases it was considered that there may have been a failure on the part of the attending midwives to identify and respond to abnormal CTG traces," wrote Andrew Freeman, chief executive of Djerriwarrh health services, the authority which runs the hospital.
"It is possible that had the abnormal CTG traces been actioned, the deaths of the babies might have been prevented.
"The deaths would not have been expected if the care and management of the mothers' labours had been different and, in particular the abnormal CTG traces actioned."
In all cases the coroner found the treatment of the babies had been "sub-optimal".
The discovery of the stillborn cluster has prompted major reform at the hospital – including the sacking of the entire hospital board by the state government.
Coroner Hawkins said in the aftermath of those changes "the community should now have confidence that the shortcomings identified have been addressed by Djerriwarrh".
