The Acting Victorian Health Complaints Commissioner, Elizabeth Langdon, has today issued a Prohibition Order against Martina Gorner and her company Ten Moons Pty Ltd, following an extensive investigation into complaints received from the public about home birthing services provided to them by Ms Gorner. The HCC had previously issued a General Health Service Warning about Ms Gorner and Ten Moons Pty Ltd in July of this year.

The Prohibition Order permanently bans Martina Gorner and Ten Moons Pty Ltd from providing any general health services including any involvement in, facilitating at, or participating in home births.

A copy of the Prohibition Order, which sets out all services Ms Gorner and Ten Moons Pty Ltd are banned from providing, is available hereThe order stipulates that Martina Gorner must not advertise or cause to be advertised, or offer or cause to be offered, or provide or cause to be provided, any general health service (paid or otherwise, in a clinical or non-clinical capacity). The general health service provider named above must not establish, direct or otherwise operate any business that provides any general health service (paid or otherwise, in a clinical or non-clinical capacity).

Ms Langdon said “the safety of Victorians continues to be our number one priority. I have issued this permanent ban on Martina Gorner and her company Ten Moons Pty Ltd from offering any general health services as I believe these pose a serious risk to the health, safety and welfare of the Victorian public.”

“My investigation found that Ms Gorner advertised, offered and provided home birth midwifery services without the appropriate registration as a health practitioner under National Law. Ms Gorner’s actions in doing so were neither safe nor ethical.”

The investigation looked closely into Ms Gorner’s management of the home birth of the complainant. An autopsy report drew a clear link between insufficient antenatal care provided to the complainant and the death of her baby. It also found that the delay in the complainant’s transfer to hospital compounded the risks to mother and baby.

“The evidence shows that Ms Gorner was responsible for both the complainant’s antenatal care—including advising her against active medical monitoring during pregnancy—and the delay in her being transferred to hospital.

My investigation found that the decisions Ms Gorner made put this woman and her unborn baby at risk.”

Ms Gorner refers to herself as an ‘unregistered midwife’ and reportedly offers and provides Syntocinon to clients. Syntocinon is listed as a schedule 4 poison (labelled “Prescription Only Medicine”), which means it may only be prescribed by a medical practitioner and administered by either a medical practitioner or nurse. Ms Gorner is not registered under National Law and therefore cannot possess, administer, or store schedule 4 poisons in Australia.

“This is a breach of Australian Law and the Code. Her actions placed multiple women and their babies at serious, arguably avoidable, risk.”

Ms Langdon further stated that her investigation found that Ms Gorner and Ten Moons Pty Ltd had committed multiple serious breaches of the Code of Conduct for General Health Services while providing home birthing services. These include:

  • Failing to provide services in a safe and ethical manner
  • Not having indemnity insurance in place to cover her practice
  • Failing to recognise the limitations of the treatment the provider can provide and refer clients to other competent health service providers, in appropriate circumstances
  • Not accepting the right of the provider’s clients to make informed choices in relation to the health services the client seeks or receives
  • Using the provider’s possession of a particular qualification to mislead or deceive clients, or the public, as to the provider’s competence in a field of practice or ability to provide treatment
  • Failing to keep appropriate records

Most general health service providers comply with their obligations under the Code of Conduct and do the right thing. However, the actions of those providers who do not, such as Ms Gorner and Ten Moons Pty Ltd, can result in serious harm to the public.  “That is why it is important for any person considering engaging with providers such as Ms Gorner or Ten Moons Pty Ltd to give great consideration as to what can go wrong and what they have a right to expect from their health service provider, so that they can make fully informed decisions.”

Any person considering any treatment should ask providers about:

  • their qualifications and experience
  • the risks involved
  • what insurance they have if something does go wrong
  • where the procedure will be carried out
  • how the procedure will be conducted
  • the products they use

Putting the Prohibition Order in place, Ms Langdon said “this should serve as a timely reminder to all General Health Service providers who do not observe the Code of Conduct that my office will investigate those providers who pose a serious risk to the public and take action against them.

 “We rely on community members to come forward with their concerns so that we are aware of possible breaches of the Code. If your expectations for safe and ethical healthcare are not met, or if you believe a health service provider is operating outside the Code of Conduct for general health services, please contact us via our online complaint form or email us at [email protected].”