An initial Health NZ report said that had the caesarean happened within an hour of the mother arriving at hospital it would have “significantly improved the outcome for [her baby] and may have prevented his death”.
Now a new decision released today by the Health and Disability Commissioner has backed the finding that the delivery should have happened sooner than it did.
HDC commissioner Rose Wall said delayed responses to a critical situation, as opposed to any lapse in care, were largely to blame.
The mother was taken to theatre and the baby born mid afternoon, “covered in blood” and in a critical condition, requiring him to be placed in the neonatal high dependency unit. Photo / 123rf
“I express my sincerest condolences to Mrs A and her husband, Mr A, for their profound loss.”
She fully supported the mother’s sentiment over wanting a safer environment, and agreed that lessons must be taken from the family’s tragic experience, and acted on to remedy the shortcomings in care.
Mother raised concerns leading up to delivery
The baby was 40 weeks and one day gestation when the mother asked to be induced.
She called her midwife, concerned about the absence of fetal movements and intermittent pain, again the following day.
The midwife in charge of her care was attending another patient, and advised the mother that her back-up midwife would meet her at the hospital.
After admission she was checked, with observations “normal”, but cardiotocography (CTG) monitoring showed an abnormal finding.
The midwife requested a medical review from the obstetrics and gynaecology registrar, then performed a procedure called a “stretch and sweep” used to induce labour. She repositioned the mother to help improve the CTG, but the variability did not improve.
The registrar assessed the mother, made a plan for further monitoring and review, then called the senior medical officer (SMO), who agreed with the plan.
The CTG trace was not shown to the SMO, nor did she request to see it, Wall said.
The hospital’s adverse event report later found that the CTG had been misinterpreted, and that it indicated fetal distress, which should have triggered “immediate management or urgent delivery”.
Deputy Health and Disability Commissioner, Rose Wall, has expressed her sincerest condolences to the parents for their profound loss.
Staff had been missing the weekly CTG education sessions because of reduced staff availability, the HDC found.
Despite a plan to review the mother within 30 minutes, the registrar did not return because she was attending an emergency.
Health NZ said there were three emergencies that day, two staff members had called in sick, and the maternity service was short by nine full-time midwives. (New Zealand was still in the grip of the Covid-19 epidemic at that time).
However, the adverse event report found the obstetrics and gynaecology team did not call for additional support, when an option existed to do this.
The mother said the midwife caring for her left the room “many times” to try and get help.
It was not known if the midwife was aware of the escalation pathway at the time, Wall said.
‘Very concerning’ find by second registrar
By the time she handed over care to another midwife, another obstetrics and gynaecology registrar was involved, who found the CTG “very concerning”.
After further investigations, he told the woman she would need a caesarean.
He requested the procedure under “category two urgency”, meaning it needed to be done within 60 minutes.
However, the adverse event report noted it should have been classified as even more urgent, which may have prevented the baby’s death.
The mother was taken to theatre and the baby born mid afternoon, “covered in blood” and in a critical condition, requiring him to be placed in the neonatal high dependency unit.
Specialist advice was sought from Tauranga and Waikato hospitals.
A retrieval team from Waikato was called but a string of challenges, including poor weather, which meant the helicopter could not land at Tauranga Hospital, and then problems with ambulance configuration, led to further delays.
Wall said the baby deteriorated while waiting for the retrieval team and was redirected to palliative care, where he died.
The adverse event report noted a delay of more than five hours in delivering the baby and that this likely contributed to his death.
The report also found deficiencies in the bereavement support provided to the family.
Health NZ apologises
Wall said the report highlighted a series of failures in the woman’s care, leading to a breach in standards by Health NZ.
She said it was clear that urgent intervention was needed, as early as the first registrar who assessed the mother but, in her opinion, the main issue that led to the baby being born in a critical condition was the delay, rather than the care that he received after delivery.
Health NZ has apologised to the family and said it has since made a number of changes to improve its practice.
Wall has issued a comprehensive list of recommendations and follow-up actions.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.