But the investigation of Royal Hobart Hospital maternity services, led by experienced nurse, midwife and health consultant Amanda Singleton, conceded staffing issues have hurt the quality of care provided to new mothers.
The wide-ranging review was sparked in August when the state nurses union alleged a baby had died during low staffing.
The union claimed women had given birth outside of birth suites, regular checks weren't being completed because of staff shortages, and babies were losing weight due to infrequent checks and lack of support with breastfeeding.
Yet the investigation could not corroborate the baby death claim after reviewing stillbirth, neonatal and induction of labour data from January 2021 to December 2024.
The state nurses union alleged a baby had died during low staffing. (Ethan James/AAP PHOTOS)
"The panel was not able to determine any association between a stillbirth / neonatal death and a delayed (induction of labour)," read the final report, released on Thursday.
"In addition, the panel conducted extensive consultations and interviews and has had no staff or community member identify such a matter."
However, it noted there were data "discrepancies" as not all third trimester stillbirths were reviewed under the terms of reference of a perinatal morbidity and mortality working group.
There was capacity for the hospital, responsible for about 2000 births a year, to carry out four labour inductions a day but they can be delayed or cancelled because of inpatient activity and staff availability.
"Women reported considerable distress at having their induction delayed," the review said.
It found staff were "disgruntled" at not being offered the same working conditions as colleagues in other wards and were not consulted when notified in mid-2024 that night duty staff numbers would be reduced by one.
"The stress the workforce is under, the skill level and the layout of the unit has a direct impact on the consumer experience and the care that they have received," the panel found.
Staff believed switching recruitment responsibility from the hospital to the state health service had protracted the process, and the panel said it was surprised there was not more emphasis on midwife recruitment.
"The impacts of the vacancy rate are wide reaching both for women and for the staff," it said.
The panel made 38 recommendations, including for the hospital to review its data collection around stillbirths and induction of labour and ensure all third trimester stillbirths are reviewed.
All have been accepted and the department has committed to forming an implementation committee.
Australian Nursing and Midwifery Federation Tasmanian branch secretary Emily Shepherd said the sheer volume of recommendations showed there was more work to be done.
"The ANMF calls on the state government to support the recommendations with adequate funding and resourcing to ensure the widespread system changes are achieved," she said.
State Health Minister Jacquie Petrusma said the government was taking the report very seriously.
"(We) want to ensure we are doing everything possible to provide safe and high-quality care to mothers and babies," she said.
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