The baby was administered saline through his nose to help with his breathing while in hospital, before being transferred to a community health service.
He continued to experience breathing difficulties and deteriorated rapidly after arriving. A post-mortem found the baby died from sepsis.
The coroner referred the case to the commissioner in 2021 to determine whether Health New Zealand had provided the baby and his mother with an appropriate standard of postnatal care in the days after his birth.
Wall said the baby died of an overwhelming infection and, while her decision had been finely balanced, she did not find there was a breach of the Code of Health and Disability Services Consumers’ Rights and the pair had been provided with appropriate care.
Appropriate steps had been taken to monitor the baby, although there were missed opportunities to take observations in the nine hours between the transfer to community health service and the discovery of the baby’s rapid deterioration, she said.
Wall made several recommendations, including that Health NZ consider the adequacy of staffing levels at community health service and the protocols in place for responding to challenging and unmanageable workloads.
Risk of infection and foetal distress
The baby’s mother had a normal pregnancy but at full term she was found to have slightly raised blood pressure and further tests detected E. coli bacteria in a urine sample.
She was induced at 41 weeks and was given three intravenous doses of penicillin during labour due to the risk of infection.
The midwife made a note of foetal distress in the baby’s newborn record, as thick meconium had been present, the baby’s shoulder had become stuck during delivery and forceps had to be used to assist with the birth.
Clinical records show the baby was floppy on delivery and appeared to need resuscitation, but on being transferred for resuscitation he cried vigorously.
Due to the risk of contracting his mother’s bacterial infection and documented distress in labour, the baby was placed under clinical assessment for 24 hours.
Regular newborn early warning scores and observations were taken every four hours as per the newborn observation chart. They included heart rate, respiratory rate, work of breathing, colour and oxygen saturation, and no concerns were noted.
No concerns were noted with the baby’s mother, the pair had skin-to-skin contact and the baby latched to the breast and was feeding well.
Three days after birth, a plan to transfer the mother and baby to a medical centre did not go ahead as the centre was at capacity and a decision was made to transfer them to a community health service.
That morning a hospital midwife noted the baby was “snuffly” at the breast and she administered normal saline drops into each of his nostrils with very little result. His newborn observation score was recorded as normal.
The pair were transferred to the community health service that afternoon, where a community health service midwife documented on arrival that the baby was pink and warm and had a normal body temperature but was uninterested in breastfeeding, and she did not note any concerns.
His parents pressed the call bell for help that evening as their baby was not interested in feeding, was mucousy and then later began to vomit, with some blood coming from his nose and mouth.
The attending midwife said she examined a tissue with a small streak of blood and had seen similar occurrences, usually from nipple trauma, so she was not worried.
By 8pm that night, the baby’s heart rate was elevated, he was notably grunting, flaring his nostrils and his lower chest wall was drawing inward.
His airways were ventilated and a team from the public hospital arrived at the community health service shortly before 10pm. The baby was intubated and, during that procedure, blood was suctioned from his mouth and lungs, indicating a pulmonary haemorrhage.
The baby was given vitamin K and cardiac compressions were commenced, but after 40 minutes resuscitation efforts were ceased and the baby died with his parents present.
Dangers of sepsis in newborns
The coroner obtained a report from a paediatrician that found newborn sepsis commonly caused rapid deterioration and death without early antibiotic administration and intensive care treatment.
The most common sign was respiratory distress, which then rapidly worsened.
When newborn infants were found to be struggling to breathe, he said it was normal to admit them to a neonatal intensive care unit and start intravenous antibiotics after checking a blood culture.
The paediatrician said respiratory distress was common, and, although most infants with it settled and did not have sepsis, this case highlighted the terrible consequences of missing the uncommon but well-recognised complication.
The on-call specialist neonatal paediatrician said the baby’s lack of interest in feeding and his blood-streaked vomit on arrival at the community health service were, in retrospect, the earliest signs of the developing infection and impending deterioration.
Deputy Health and Disability Commissioner Rose Wall. Photo / Lance Lawson
Commissioner’s recommendations and Health NZ’s response
Wall recommended Health NZ consider the adequacy of staffing levels at community health services and the protocols for responding to challenging and unmanageable workloads.
She also recommended the organisation consider implementing a protocol requiring a full newborn observation chart/newborn early warning score be undertaken on an infant prior to departure and on arrival for transfers between primary unit maternity services and that it draft an educative piece on sepsis in newborns, with a summary of the case to be shared with the wider organisation.
In response, Health NZ said it had increased staffing levels at the community health service, so there were two midwifery staff rostered per shift and provided an educational summary of the case, focusing on the expectations around observations, particularly for the safe transfer of a mother and baby as per the transfer guidelines, had been presented to staff.
Wall asked that the baby’s parents be provided with a written apology highlighting the issues and lessons from the case, within three weeks of the report’s release.
– RNZ