The Douglas Inquiry investigated the Obstetrics and Gynaecological services at King Edward Memorial Hospital from 1990Hospital from -2000 Identifying and investigating performance issuesIn 1999, the recently appointed Chief Executive at King Edward Memorial Hospital (KEMH), Mr Michael Moodie, gave evidence to the Western Australia Metropolitan Health Service Board (MHSB) of poor management and clinical performance at the Hospital. His concerns included the Hospital's lack of an overall clinical quality management system, failure by senior management to resolve long-standing clinical issues and inadequate systems to monitor and report adverse clinical incidents. Other issues included the absence of a proper and transparent system to deal with patient complaints and medico-legal claims, a shortage of qualified clinical specialists particularly after hours, the inadequate supervision of junior medical staff and evidence of sub-standard patient care.After some delay, the MHSB commissioned a review of the Hospital's Obstetric and Gynaecology services by an independent clinician. The review raised more management and clinical performance issues and recommended further investigation. In consultation with the Health Commissioner and the Minister, the Chief Medical Officer and the MHSB Chief Executive Officer subsequently commissioned another review (Child and Glover 2000). This two-week review identified significant system and performance issues. As a result, the Minister in consultation with the Premier commissioned Mr Neil Douglas (a lawyer) to lead an inquiry into obstetrics and gynaecological services at KEMH (Douglas, Robinson and Fahy 2001). This report uses the terms "Inquiry" and the "Douglas Inquiry" interchangeably.Over eighteen months, the Inquiry investigated clinical and management practices at the Hospital from 1990-2000 and recommended changes to address service deficiencies.

Hospital morbidity data were analysed to determine their usefulness for reporting adverse events.

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