Clinical governance — structured oral station (12 minutes)

Opening prompt — "Describe your governance response to this event."

Model response — the 24-hour actions in order: ^[2][6]

• "Stabilise the clinical situation — confirm the baby is receiving therapeutic hypothermia, ensure the mother is medically stable and supported."
• "Preserve the records — secure the CTG, the partogram, the operation notes, the staffing roster; do not alter anything."
• "Escalate and report — notify the executive on call, enter the event in the incident-management system, and notify the sentinel-event programme as required."
• "Support the night registrar now — she is a second victim; I would name a senior to be with her."^[4]
• "Open disclosure to the family — early, honest, with an apology."^[5]

Probe 1 — "Walk me through your root cause analysis."

• "I would use the London Protocol — what happened, why, what can reduce recurrence, then implement and monitor."^[3]
• "I would chart contributing factors on a fishbone across people, process, equipment, environment, management and patient factors — the prolonged second stage, the recurrent late decelerations, the escalation pathway, the staffing, the supervision, the cognitive load on the night team."^[3]
• "Crucially, I would hold the system lens, not the person lens. 'Human error' is a consequence, not a cause — the question is why the late decelerations were not escalated, and what conditions allowed that. We cannot change the human condition, but we can change the conditions under which humans work."^[2]

Probe 2 — "The registrar says she didn't call you because the last time she escalated overnight she was told off. How do you respond?"

• "That tells me the culture is the latent condition — a culture where escalation is punished is the hole in the cheese. The RCA has to reach that, and the corrective action is cultural, not just a new CTG rule."
• "I would support her now, explicitly separate her from blame, and make clear that escalation is always welcome and never penalised. A just culture distinguishes human error from reckless conduct; this was error in a flawed system."^[2][4]

Probe 3 — "How do you do the open disclosure?"

• "I would meet the parents in a private space, with a support person and a neonatologist, sit at their level, and give a factual account of what we know — the labour, the monitoring, the outcome, and that the baby is receiving cooling."
• "I would apologise early and genuinely: 'I am so sorry this has happened.' Under the Australian framework a genuine apology is an expression of regret, not an admission of liability."
• "I would be honest that we do not yet know all the causes, commit to a thorough investigation, and arrange follow-up. I would document the conversation, who was present, and the plan."^[5]

Probe 4 — "How do you prove the unit has improved?"

• "I would run a clinical audit: define the standard (escalation of a pathological CTG to the consultant within a defined window), set the threshold, measure current compliance, analyse the gap, intervene (a clear escalation pathway, a culture that rewards calling), and re-audit after the change to demonstrate improvement."
• "I would use run charts or SPC charts to show the board the trend over time — not raw counts. And I would close the loop with the family — share the findings and the actions."^[6]

Probe 5 (communication) — "The registrar is in front of you, in tears. Talk to her."

This is a scored domain. Demonstrate it out loud: ^[4]

• "Thank you for telling me what happened. This was not your fault alone — a number of things lined up that should not have, and we are going to look at all of them together. I am going to make sure you are supported. I want you to know that you did the right thing in the end, and that calling for help is always the right thing here. Let's get you some support today, and we will go through this properly."