The Vancouver Island Health Authority (VIHA) has released its external review into the death of an infant at Victoria General Hospital in August 2011. That review concluded that a c-section was provided within guidelines (20 minutes after being ordered).
It really is an interesting read and gives the depiction of an ongoing situation of sub-optimal maternal and fetal care in Victoria, particularly since the provision of anesthesia services to the labour and delivery ward was reduced as of May 31, 2010. VIHA has also released its response to the recommendations.
The problem I have is that the review indicates that there have been past concerns - these concerns were identified both prospectively (Failure Modes and Effects Analysis) as well as retrospectively (the Qmentum accreditation process also identified and recommended an immediate remediation of the problem). Those reports happend in 2010 - and yet it took a baby death in August 2011 to spark an external review that basically recommends what has already been recommended. I'm not left with a lot of confidence that anything will change.