S3 E3 Redesign of the Victorian Perinatal Autopsy Service

In this episode of our mini-series on perinatal pathology, RCPA President, Associate Professor Trishe Leong is joined by anatomical pathologist Dr Jackie Collett and perinatal autopsy service coordinator Nicole Vander Linden, who work together at the Victorian Perinatal Autopsy Service (VPAS), at the Royal Women’s Hospital in Melbourne.

Together, Jackie and Nicole emphasise the collaborative effort required to deliver effective perinatal pathology services. They also discuss the establishment of VPAS and how they have been centralising the autopsy referral process to improve the experience for bereaved families.  

Transcript

00:00:06:18 - 00:00:14:08

Dr Jackie Collett

It’s a very different way of thinking about pathology. And that’s one of the things that I find really interesting.

00:00:14:10 - 00:00:29:07

Nicole Vander Linden

Providing this service for bereaved families is a very important objective for our service, and it is very much a part of our thinking in terms of our redesign.

00:00:29:09 - 00:00:32:21

A/Prof Trishe Leong

I am Associate Professor Trishe Leong, the President of the Royal College of Pathologists of Australasia.

00:00:32:21 - 00:01:17:12

A/Prof Trishe Leong

Hello and welcome back to this RCPA podcast series on perinatal pathology. I’m Associate Professor Trish Will and I’m President of the Royal College of Pathologists of Australasia. In an effort to shine a light on this important area pathology and hopefully encourage Trainees to consider a career in this special discipline. We’ve been speaking to perinatal pathologists and their colleagues across Australia, and, in this episode, we’re joined by anatomical pathologist, Dr Jackie Collett and perinatal autopsy service coordinator Nicole Vander Linden, who work together at the Victorian Perinatal Autopsy Service, or otherwise known as VPAS at the Royal Women’s Hospital in Melbourne.

00:01:17:14 - 00:01:47:05

A/Prof Trishe Leong

VPAS provides a coordinated statewide service that ensures consistent standards of practice and expertise for the clinical investigation of perinatal deaths across Victoria. This service is available to public as well as private patients and there’s no charge for autopsies on deceased babies where there’s a registered perinatal death. Services are provided by the Royal Women’s Hospital, Monash Health and the Mercy Hospital for Women and their respective pathology service providers.

00:01:47:07 - 00:02:00:18

A/Prof Trishe Leong

Incidentally, I happened to have a bit of an insight into VPAS because I previously worked at the Mercy Hospital for Women. So very interested in it for today’s project. Hi Jackie and Nicole. Thank you both for joining us today.

00:02:00:20 - 00:02:01:24

Nicole Vander Linden

Thank you.

00:02:02:01 - 00:02:04:09

Dr Jackie Collett

Thanks very much for having us.

00:02:04:11 - 00:02:25:00

A/Prof Trishe Leong

So, Jackie. All parents should have the option to know why their baby died. And VPAS is fully funded for parents who need it. And there are three Victorian tertiary maternity hospitals that are providing these services. Maybe you could explain a little bit more for our listeners what these services exactly are.

00:02:25:02 - 00:02:51:13

Dr Jackie Collett

Well, VPAS stands for the Victorian Perinatal Autopsy Service, and we provide a statewide service for perinatal autopsies, and that’s a collaboration across several health services. VPAS was set up following a tragic cluster of perinatal deaths that occurred at Djerriwarrh some years ago. And the Department of Health made a number of changes, including the formation of VPAS.

00:02:51:15 - 00:03:31:03

Dr Jackie Collett

Up to that point, perinatal autopsies could be provided in any pathology laboratory across the state. This meant that some locations did quite small numbers. And this is an area where there’s been progressively increasing specialisation and expertise over the years. And it was felt that really centralising the autopsy service to areas that had appropriate perinatal expertise was appropriate. So what the government did was ask that all perinatal autopsies be performed at the three maternity, tertiary centres and their pathology providers or pathology partners.

00:03:31:05 - 00:03:53:11

Dr Jackie Collett

Now, many of the perinatal deaths in Victoria do occur at those centres because they manage very high-risk pregnancies. And those high-risk pregnancies may be associated with some perinatal death. So a number of the deaths do occur there, but the remainder of the deaths, of course, occur at all sorts of maternity centres across the state and very often in what are otherwise normal pregnancies.

00:03:53:13 - 00:04:24:10

Dr Jackie Collett

And so those babies that are born elsewhere have to be brought to these tertiary maternity centres in the pathology laboratories. So there’s an element of transportation that needs to be provided, and VPAS covers these costs of transportation. Then the autopsies are performed at the three laboratories and are performed by perinatal pathologists. We’ve got a slightly different model, perhaps in Victoria to some of the other states. Our pathologists do tend to be involved in other pathology at those sites.

00:04:24:10 - 00:04:47:20

Dr Jackie Collett

So they might be doing general pathology or they might be doing obstetric and gynaecological pathology, but they all have a specialist interest in perinatal pathology and will do quite a lot of perinatal autopsies each year. So they have the appropriate skills and proficiency. In other states, a lot of the period natal pathologists are paediatric pathologists working at specialist children’s centres.

00:04:47:20 - 00:04:50:17

Dr Jackie Collett

So we had a slightly different model here.

00:04:50:19 - 00:04:57:13

A/Prof Trishe Leong

So Jackie, you’re medical head of the unit at VPAS. What does your role entail?

00:04:57:15 - 00:05:30:07

Dr Jackie Collett

Well, I might start first off with what the aims of VPAS. The aims of VPAS are to have excellence in the provision of perinatal autopsy services and to engage in continuous quality improvement. We are also supposed to engage with activities that will reduce perinatal morbidity and mortality. And importantly, we’re tasked to ensure that there’s equity of access to perinatal autopsy services for all Victorian families who are affected by perinatal loss.

00:05:30:09 - 00:06:00:10

Dr Jackie Collett

My role as the medical lead is to provide the clinical leadership in this space, so I oversee aspects of the provision of a quality autopsy service and try and work to get some consistency of the offering and to look at aspects of things that we can work on improving the quality of, and also to look at how we might use the funds that we have for the provision of autopsy in a judicious sort of fashion.

00:06:00:12 - 00:06:24:23

Dr Jackie Collett

I guess one of the other parts of my job description is to consider the integration of new technologies and I guess the sort of things that that might be are, for example, how we might use postmortem MRI in the provision of autopsies and how we might modify the way we integrate that into autopsy provision. And another area might be the emerging technologies in genetics.

00:06:24:23 - 00:06:52:23

Dr Jackie Collett

So things like whole exome sequencing and how that is incorporated into autopsy practice and what things we should modify in what we’re doing to, again, use the funds judiciously and not duplicate work. Following on from the Djerriwarrh cluster of preventable deaths that occurred, one of the things that VPAS was asked to do was to play a role in identifying any systemic issues of concern in perinatal care.

00:06:53:00 - 00:07:12:16

Dr Jackie Collett

It’s kind of hard to do just based on the autopsy service alone, because we don’t see all the perinatal deaths in the state. So it’s a bit of a challenge for us to pick up on any trends, but obviously we do bear that in mind should we become aware of anything that we think is important, we would escalate that appropriately.

00:07:12:18 - 00:07:41:04

Dr Jackie Collett

But we do support this work by participating in a lot of meetings. So, for example, there’s a Victorian statutory authority called the Consultative Council on Obstetric and Paediatric Morbidity and Mortality, much more conveniently called CCOPMM. And I certainly attend a number of their subcommittee meetings to present the findings from perinatal autopsies and placental pathology to support their work in reviewing perinatal deaths in Victoria.

00:07:41:06 - 00:08:07:19

Dr Jackie Collett

Nicole and I are very active also in a lot of educational activities, so we do a lot of work with midwife in service sessions, educating them about what perinatal autopsy involves, because we know that midwives are often the people who answer a lot of questions about perinatal autopsy. We’ve also been coordinating registrar education around perinatal pathology, those registrars that actually come and work in the centres where the autopsies are provided.

00:08:07:19 - 00:08:30:24

Dr Jackie Collett

We’ve been involved in supporting the education for them and we’ve also had a local virtually run perinatal pathology interest group meeting that we’ve run in previous years. It’s going through a little bit of a change in sort of direction at the moment, but it’s another part of the sort of educational sort of work that we’ve been doing. Probably, as you can gather, there’s a lot of different areas that interact in the area of perinatal autopsies.

00:08:30:24 - 00:09:03:02

Dr Jackie Collett

So my role is to promote stakeholder engagement across that spectrum. So that’s the participating labs and health services. A lot of these Department of Health based sort of services like Safer Care and CCOPMM and we do even collaborate with the Victorian Institute of Forensic Medicine by doing some of the perinatal autopsies of babies that come through there. But we also do just collaborate with them around the whole issue of provision of perinatal autopsy services as well.

00:09:03:04 - 00:09:08:13

A/Prof Trishe Leong

And how was the medical head of unit role at VPAS developed?

00:09:08:15 - 00:09:32:06

Dr Jackie Collett

So my role is funded as at one day a week. So it is a part time role. I guess there’s been three distinct phases to the role of the medical lead in VPAS. The first medical lead for VPAS was actually Associate Professor Kerryn Ireland-Jenkin. She was the initial person appointed as the head of VPAS and she was involved in the set up of VPAS at the beginning.

00:09:32:06 - 00:09:53:18

Dr Jackie Collett

So there was obviously quite a bit of administrative and governance sort of stuff to set up at the beginning of the service. So I think a lot of her time was probably spent in those sort of activities. She was in that role for a few years and then I really came in after that set up process had occurred probably two years after that.

00:09:53:20 - 00:10:14:22

Dr Jackie Collett

And so it was an established service at that point. And so I was able in the first few years of my role to become involved in the educational and stakeholder engagement aspects of the role. I think now the role that I’m in is, is in a third phase and it’s quite busy and very interesting. We’re really developing VPAS 2.0, if you like.

00:10:14:22 - 00:10:47:19

Dr Jackie Collett

It’s almost starting again from the ground up, redeveloping the role. Up until now, although we’ve had a bit of an administrative function with the federal funding that has come through related to the stillbirth implementation of the Stillbirths Subcommittee recommendations, we’re actually about to launch a truly centralised referral service for organising perinatal autopsies where clinicians can ring up and get advice and help in organising a perinatal autopsy and also advice around other aspects of perinatal loss.

00:10:47:19 - 00:11:23:04

Dr Jackie Collett

And so we’ve been through a process of employing some new staff in perinatal autopsy coordinator roles. We’ve had to look at IT solutions as to how the centralized process might work from an IT and information management point of view. We’ve also been working through a transport tender process to provide a fairly priced and professional transport service for moving babies to autopsy and quite a lot of collaboration with the labs, working through all the various aspects of this to make it work smoothly from the laboratory point of view.

00:11:23:04 - 00:11:37:23

Dr Jackie Collett

So there’s really been a number of different phases of the role. And I guess after this work’s complete, then once again it will go back to perhaps more of the educational and stakeholder involvement type aspects of the role again.

00:11:38:00 - 00:11:47:17

A/Prof Trishe Leong

So Nicole is the perinatal autopsy service coordinator at VPAS. How does her role interact with roles?

00:11:47:19 - 00:12:17:03

Dr Jackie Collett

Nicole and I work very closely, and I must say following COVID virtual meetings have helped a lot in this space, as we’ve mentioned, there’s a variety of stakeholders involved. The other practical aspect is that because I’m one day a week, it’s very hard to confine this sort of stakeholder engagement to a single day a week. So Nicole and I actually tend to touch base most days and I tend to distribute the work across the days.

00:12:17:05 - 00:12:45:03

Dr Jackie Collett

Nicole can probably talk more about what her role involves shortly, but I think Nicole and I have very complementary skills, but a lot of our work actually involves working together, deciding who’s going to do which task, which is often more of an administrative type thing. We also work very closely with the director of Allied Health and Clinical Support Services here at the Women’s, whose portfolio VPAS falls under as an administrative unit.

00:12:45:07 - 00:13:10:03

Dr Jackie Collett

So we do have a lot of meetings. So we talk a lot. We talk about, you know, how the service is going to be developed, the issues that are currently need to be managed. And we have a couple of committees that are tasked with overseeing the service. We have to coordinate the work of the committees and stuff. So we just have to touch base with each other quite a lot about a lot of these sort of ongoing issues.

00:13:10:05 - 00:13:19:02

A/Prof Trishe Leong

So over to you now, Nicole. Can you explain how you work with Jackie and her team and what updates are being made to the services at VPAS?

00:13:19:04 - 00:13:59:19

Nicole Vander Linden

Thanks, Trishe. I’ve had the pleasure of working with Jackie over seven years and she is the clinical expert for VPAS as the medical lead and the subject matter expert for perinatal autopsy and perinatal pathology. And so her and I work together to manage a range of issues like she’s just indicated from the committee level in that we have our technical advisory committee and an executive oversight committee that manages a range of issues from day-to-day work in the laboratory to the more strategic planning type work that’s done within the executive oversight committee and the oversight that that committee gives to the rest of the service.

00:13:59:19 - 00:14:26:05

Nicole Vander Linden

Because although the services provided by the laboratories, it was designed to be a maternity service led system. So we really need the maternity services to have that oversight of how this service is being provided around the state. We often collaborate in different projects in terms of at the moment we’ve been working through the redesign of our service.

00:14:26:07 - 00:15:00:12

Nicole Vander Linden

So previously our service had been the last to find out about the autopsy and we were looking after the data and the finance budget, payment of invoices and looking after those administrative type functions. And now we are moving towards being able to provide a front-end service. So actually being the group that receives the referral for the autopsy and then coordinates the process of getting that baby transferred, collating all of the paperwork, preparing the case for the pathologist to then undertake their work.

00:15:00:18 - 00:15:31:24

Nicole Vander Linden

And then at the other end of that process, arranging for the repatriation of the baby to come back to the family. So my role interacts with Jackie’s, like Jackie mentioned, on a really regular basis. And we now have a small team that we are working with as well. We’ve had a job share position created for two perinatal autopsy coordinators who are currently working with us to expand how our service works and to really provide an end-to-end support for how this process happens.

00:15:32:01 - 00:15:40:21

A/Prof Trishe Leong

Why is it important to provide the service for bereaved parents and how those changes you mentioned helping to support families, do you think?

00:15:40:23 - 00:16:07:16

Nicole Vander Linden

Providing this service for bereaved families is a very important objective for our service and it is very much a part of our thinking in terms of our redesign of VPAS. Currently, I think midwives and obstetric teams out in the community who are working with families that are confronted with this situation may have never done this work before. They may never have confronted a deceased baby or this scenario.

00:16:07:17 - 00:16:32:01

Nicole Vander Linden

And so we are wanting to provide that support to the clinicians in the first instance to be able to really help them to navigate this in a more comprehensive way and in a way that really supports the family so that we’re not expecting midwives and obstetric staff or paediatric staff who are not familiar with this process to do it at a standard that we in the laboratories who do it all the time would expect.

00:16:32:01 - 00:16:54:20

Nicole Vander Linden

So we’re trying to really bridge that gap and to enable the clinicians to provide a really exceptional experience for the family who have been confronted with this horrible situation. So I think that being able to provide a centralised service really enables VPAS to be able to make the terrible situation that the family are in better rather than worse.

00:16:54:20 - 00:17:25:22

Nicole Vander Linden

So we don’t want our system to be one that puts obstacles in their way, that doesn’t provide them with good information. And that leaves clinicians in a situation where they’re floundering and therefore causing that impact on the family. So part of what VPAS is doing is providing that information to clinicians to assist them to provide good care in this space, and then also providing the opportunity for families to contact us if they need to be updated about where their baby’s at in the process.

00:17:25:24 - 00:17:47:02

Nicole Vander Linden

So this is a very different model for VPAS to be embarking on, and it’s very different to what we have been doing in the past. But we’re really hopeful that it’s going to have a really important benefit to bereaved families so that the service that they receive is a part of supporting them through a difficult time rather than making it a difficult time worse.

00:17:47:04 - 00:18:11:19

Nicole Vander Linden

And then the other reason why it’s important for us to provide this service is for the understanding of clinicians, the understanding of the hospital that the baby has been born into. If there’s any quality improvement type reasons why this has happened, and then also looking at the community level to ensure that the community is able to learn and to obtain the best quality data around why babies are dying in different scenarios.

00:18:11:21 - 00:18:16:22

A/Prof Trishe Leong

And what do you like about working with Jackie and other perinatal pathologists?

00:18:16:24 - 00:18:42:18

Nicole Vander Linden

I have a great deal of respect for the work that Jackie and her colleagues do in the perinatal autopsy space, and I definitely would not be able to do what they do. And I very much enjoy working with Jackie. We have a great working relationship and it’s been a pleasure working with her. But I think the thing I really like about working in this space is that the practitioners such as Jackie and the other perinatal pathologists, that they’ve got a really curious mind.

00:18:42:18 - 00:19:08:23

Nicole Vander Linden

They look at problems in an interesting way and they are dealing with a tragic situation. But they are also processing that the clinical information and they’re creating a report that’s really helping the families to make further decisions into the future about their next pregnancy or their understanding how they process this death of their baby. They’re bringing all of this information, all of this knowledge and experience together.

00:19:08:23 - 00:19:48:09

Nicole Vander Linden

And, you know, I think it is a confronting space to work with. And Jackie and I often have this banter back and forward about how I find this area a difficult area to work within sometimes, whereas it’s the work that she does and it’s very familiar to her and she’s very comfortable in that space. So I think that the curiosity and the excitement that they have in working in this space and in being able to formulate all of what they bring to the diagnostic process, it really makes that difficult edge of being involved in what is essentially, you know, an autopsy of a deceased baby and all of the implications that that has it kind of makes it an easier thing to be involved in.

00:19:48:09 - 00:20:12:21

Nicole Vander Linden

And I think it’s also very meaningful work and it has a very significant impact on the families that have suffered such a terrible thing to be able to assist them in providing meaning, to be able to assist in the medical lead role, the clinicians to help families understand what’s happened, to help them understand the value of a negative autopsy.

00:20:13:01 - 00:20:39:16

Nicole Vander Linden

Like if an autopsy doesn’t find anything, I think Jackie’s just really got a very I was thinking about this question a lot, trying to figure out what it is. But she’s just got a gift for being able to communicate the value of the autopsy in a way that is really she’s very popular speaker in our area. People want to have her come and do the presentations because she’s just got a gift for that.

00:20:39:18 - 00:20:57:23

A/Prof Trishe Leong

The RCPA has raised concerns about a lack of perinatal pathologists. How would I suppose a shortage of perinatal pathologists or being unable to fill a position if it was vacant? How would that impact the services that you provide at VPAS?

00:20:58:00 - 00:21:24:19

Nicole Vander Linden

So there is a bit of a combination of issues in regards to the perinatal pathologist workforce. apart from the fact that perinatal autopsy and performing autopsy can I think if you went out into the community and asked, you know, people would generally say it’s a difficult and challenging area to work within. And I think there’s also at the same time as that particular perspective on working in autopsy, that sometimes it’s, you know, that it can be a difficult space.

00:21:24:21 - 00:22:05:00

Nicole Vander Linden

There’s also the fact that there’s been a change in the requirement for perinatal pathologists to do autopsy in their exam and in their examinations. And so those two things combined does actually mean that there is a prospect of there being inadequate numbers of appropriately trained perinatal pathologists. And I think the capacity of our service to provide meaningful autopsy reports in a timely fashion, it will definitely be impacted if there are not enough of that particular group of clinicians. As that number reduces, the capacity to train future pathology Trainees in that area will also be challenged.

00:22:05:00 - 00:22:32:20

Nicole Vander Linden

So I think that there are significant headwinds for that group of clinicians and it is extremely important that we’re able to the pathologists are not just doing the autopsy, that they collating the history of the pregnancy, the history of the mother, the baby. And they’re looking at all of the results and the findings of the autopsy. And they’re producing a report that’s going to provide meaning in, you know, at the state level and at the family level and at the hospital level.

00:22:32:20 - 00:22:46:05

Nicole Vander Linden

So there’s significant outcomes that are going to happen from that report. And knowing that there are those headwinds is something that we’re working on in VPAS to try and help with that. But I think that, you know, it’s a significant issue.

00:22:46:07 - 00:23:00:10

A/Prof Trishe Leong

So back to Jackie now. Through this podcast, we hope to encourage Trainees to consider a role in perinatal pathology. So what would you say to someone who maybe hasn’t considered a career in this area before?

00:23:00:12 - 00:23:37:03

Dr Jackie Collett

Well, I think to use Nicole’s word from earlier, this is really meaningful work. And I’m always impressed, particularly when I go to the regional and state level morbidity and mortality meetings at how much the autopsy work that we do is appreciated and used by people in modifying their practice. And obviously in feeding back to the families as well, but also in terms of informing appropriate modifications of practice and how the systems in the state can be changed to provide better care for mothers and babies during pregnancy.

00:23:37:08 - 00:24:02:02

Dr Jackie Collett

But leaving aside the meaningfulness of the work just from a very sort of self-interested point of view, it’s really interesting work. It’s not an area that, of course, people necessarily understand all that well, depending on their education during their training as a doctor, they might not have done much obstetrics and gynaecology. And the placental pathology tends to be perhaps a less well understood area of pathology.

00:24:02:02 - 00:24:28:06

Dr Jackie Collett

But it is actually really interesting work and autopsy work in general. I was very fortunate to train during a time when autopsy work was much more common and autopsies are the long cases in pathology, surgical biopsy work tends to be kind of a much more short case orientation. And the autopsy work really requires us, again, to sort of mention stuff that Nicole has already said.

00:24:28:08 - 00:25:03:14

Dr Jackie Collett

This integration of multiple threads of information from the clinical history, from laboratory investigations, radiological investigations, the actual autopsy itself, and to have an understanding of the clinical setting of obstetrics and gynaecology. It’s also one of the areas of pathology where you actually need to have a bit of an understanding of mechanical factors. You have to think about a baby in a uterine environment, and then during labour and delivery, the change in physical position of a baby and its transition, it’s a very different way of thinking about pathology.

00:25:03:18 - 00:25:22:18

Dr Jackie Collett

And that’s one of the things that I find really interesting. I guess also it’s a bit strange to say, but as a pathologist, I can’t actually think of anything worse than sitting all day at the microscope and autopsy work is actually one of the areas where you get really a lot of variety in your day. You’re doing things in the autopsy suite.

00:25:22:20 - 00:25:46:20

Dr Jackie Collett

You’re you are doing some microscope work. You are talking to clinicians about a clinical situation related to perinatal autopsy. And then obviously, in the role that I’m in, in this work with the VPAS, I’ve also got a bit of an administrative role as well. So it’s a it’s a really interesting and varied area of pathology. And I guess that’s probably one of the things that I like about it most.

00:25:46:22 - 00:26:17:23

Dr Jackie Collett

And I think it’s one of the reasons why people should have a think about it. There is, of course, that bit of a yuck factor about the idea that it’s an autopsy. But I have to say, when we have Trainees come through, although that’s perhaps a bit of an issue to begin with, once people overcome that sort of hurdle, I think they understand the sort of things that I’ve described about the meaningfulness of the work and then can see the interest in the area and are often really keen to engage with it.

00:26:18:00 - 00:26:43:15

A/Prof Trishe Leong

Thank you both, Jackie and Nicole. As we conclude this episode of our perinatal pathology series, we delved into the crucial work of the Victorian Perinatal Autopsy Service at the Royal Women’s Hospital in Melbourne, with insights from Dr Jackie Collett, the medical head of unit and Nicole Vander Linden, the perinatal autopsy services coordinator. Together, Jackie and Nicole have emphasised the collaborative effort required to deliver effective perinatal pathology services.

00:26:43:16 - 00:27:10:22

A/Prof Trishe Leong

Their dedication to ensuring compassionate care for every family reflects the heart of VPAS’s mission. They also address the concerning shortage of perinatal pathologists and highlighted the importance of attracting new talent to this vital field. We hope this episode has shed light on the invaluable work of perinatal pathology services like VPAS and inspired future pathologists to consider a career dedicated to supporting families during their most challenging month.