The review made 21 recommendations aimed at improving patient care. Virginia Mayo/Associated Press

A review into a stillbirth last month at Victoria General Hospital has found there were no delays in providing anesthesia to the mother.

The review, released by the Vancouver Island Health Authority on Monday, was ordered after anesthesiologists — who are currently in a pay dispute with the health region — blamed the infant's death on a lack of timely care due to a shortage of anesthesiologists at Victoria General Hospital.

An independent report into the incident concludes the number of anaesthesiologists on duty wasn't to blame, and an emergency caesarean section started 20 minutes after it was ordered — well within the recommended response time of 30 minutes.

The anaesthesiologist in the hospital was working on another operation at the time, so the C-section was conducted in an adjacent operating room, which the report says had no impact on the baby's health.

However, the report does point to other issues that may have played a role in the infant's death.

The report notes family physicians — not obstetricians — deliver even high-risk babies in Victoria, and in this case the degree of risk to the baby by its very obese mother may not have been identified.

The report also says there could have been better communication between the operating room team and the maternal delivery department.

The report makes 21 recommendations, including:

• The creation of a three-level maternal and fetal healthcare program
• Proactively determining whether patients are considered high-risk.
• Working closely with midwives to ensure they are part of the model of obstetric care in Victoria.
• Establishing a dedicated obstetrical anesthesiology service.
• Improved patient engagement.
• Better training and development among hospital staff.

A former anaesthesiologist at the hospital, who wasn't involved in the case, issued a letter to media outlets warning that staffing levels at the hospital could have been a factor in the stillbirth.

The B.C. Anaesthesiologists' Society was also quick to jump on the case.

But the provincial government and the Vancouver Island Health Authority said at the time that the hospital has a full complement of the specialists.

The government and health region said they have both wanted to add an obstetrical anaesthesiologist, but the Anaesthesiologists' Society has refused to fill the position because of a fee dispute.

While the newly released report says the dispute wasn't a factor in the outcome of the stillbirth, it says the dispute has hurt patient care and urges that obstetrical anaesthesiology service be restored.

The Vancouver Island Health Authority says it will adopt all of the recommendations from the independent review.

With files from The Canadian Press