“We had finally been able to see a specialist after delays, I just wish it was someone who did their job properly so our son could have had a fighting chance.”
The HDC has now found Te Whatu Ora breached the Code of Health and Disability Services Consumers’ Rights after it failed to provide the woman with reasonable care and skill, through failing to appropriately manage abnormal ultrasound findings.
Baby’s growth a concern
According to a decision released today, the woman, who has name suppression, became pregnant via IVF in 2021.
In late August 2021, when she was 26 weeks and 4 days’ gestation, she had a growth scan after her lead maternity carer (LMC) recognised an August 11 scan had shown growth under the 5th percentile, and a possible intrauterine growth restriction (IUGR).
An August 30 scan showed the fetus was small. The amniotic fluid volume and Doppler ultrasound scan were normal.
Recommendations were made for further serial growth scans and Dopplers, and a repeat scan was booked for September 14, 2021.
The LMC referred her for a specialist consultation because of the findings. It appears that it was not possible to immediately schedule a face-to-face specialist appointment.
On September 8, 2021, the woman had a phone consultation with an obstetrician and gynaecologist consultant from Southland Hospital.
They reviewed her medical history and most recent scans, and the consultant organised a TORCH screen blood test for unexplained IUGR.
A TORCH screen is a blood test used to screen for infections that can cause complications in pregnant women and harm to a developing fetus. The TORCH screen showed the woman had no current infection.
She then underwent an ultrasound scan on September 14, 2021.
An abnormal Doppler finding was uncovered but was not included in the opinion section of the sonographer’s report.
Health NZ told HDC that standard management for IUGR is weekly ultrasound with Dopplers; if any abnormal Dopplers are identified, then twice-weekly Dopplers are performed. If these Doppler results worsen, or maturity is reached, the baby should be delivered.
Health NZ accepted that none of this was done.
‘Critically short-staffed’
On September 22, 2021, the woman was seen in the Antenatal Clinic at Southland Hospital by a locum obstetrician and gynaecologist.
Health NZ told HDC that there was often “little opportunity for orientation for locums in the obstetrics and gynaecology department as the service has been critically short-staffed”.
It also said it was experiencing “extreme pressure” under which the department was working at the time, while trying to manage Covid-19.
The doctor discussed the results of the TORCH screen with the woman who told the HDC “it became apparent during this consultation that he had no idea about any of my history as he did not have my notes available.
“I had to share my own LMC notes … which he barely glanced at”.
She said the doctor brushed off her concerns when she tried to stress to him that her LMC and sonographer were “very concerned” about fetal growth.
The clinic letter the doctor subsequently drafted stated that the woman reported good fetal movements, that, clinically, the uterine size was compatible with the gestation of 29 weeks, and that the fetal heart rate was heard.
The fetal heart rate was not recorded, and, in response to the provisional opinion, the woman told HDC that she did not report “good fetal movements”.
The doctor documented in the clinic letter that the fetal weight was at the 10th percentile on the GROW chart, which tracks the height and weight of a fetus against percentiles, and that the liquor volume, the volume of amniotic fluid surrounding a fetus during pregnancy, and Dopplers were normal.
Southland Hospital in Invercargill.
Photo / Allison Beckham
The woman’s blood pressure was slightly elevated, so the doctor requested pre-eclampsia blood tests, but if continued scans were normal she would likely deliver at 37 weeks.
Health NZ told HDC that, in retrospect, further investigations should have been undertaken when the doctor saw the woman.
However, it noted the doctor’s actions were based on the findings in the opinion section of the ultrasound scan report from September 14, 2021, which did not include the abnormal finding recorded in the body of the report.
A stillborn baby
On September 26 the woman contacted her LMC as she did not feel the baby moving.
She was referred to Southland Hospital, where she had an ultrasound that confirmed the baby had died. She underwent an emergency c-section to deliver her stillborn son.
She told the HDC that after the loss of her baby she was told she would be seen in the antenatal clinic at Southland Hospital in six months, for a debrief with clinical staff once the autopsy results had been received.
Despite this, nine months later she had not received a follow-up appointment.
Health NZ said it sincerely apologised for the delay in arranging a follow-up appointment and that the service had been under immense pressure and had been challenged by long waiting lists.
‘Learnings that can be taken from our experience’
The woman told the HDC that there were learnings Health NZ needed to take from their experience.
“We understand that as humans we all make mistakes and that in order to progress, we need to own it, fix it and learn from it,” she said.
“Although there is nothing that can be done to fix losing our precious son, there are learnings that can be taken from our experience, to help improve our health system for other expecting mothers.
“We left the hospital that day feeling dismissed, not listened to and feeling really uneasy about the situation.”
Deputy Health and Disability Commissioner Rose Wall said several factors contributed to the shortcomings of the woman’s care.
Deputy Health and Disability Commissioner Rose Wall.
“I consider that these shortcomings represent systemic failures for which ultimately Health NZ is responsible at an organisational level.”
Wall found Health NZ in breach of the Code of Health and Disability Services Consumers’ Rights for failing to provide the woman with reasonable care and skill through failing to appropriately manage abnormal ultrasound findings and IUGR.
“Southland Hospital did not undertake an adverse event review after the stillbirth of [the baby]. In my opinion, this was a valuable opportunity for its obstetric service to learn from this episode and make the necessary changes to its systems and processes to help prevent a repeat of [the couple’s] tragic loss.”
‘Deeply sorry’
David Gow, Health New Zealand Chief Medical Officer – Southern and Te Waipounamu, said the organisation was deeply sorry for the distress caused and recognised “the profound long-lasting impact”.
He acknowledged the Commissioner’s findings and had apologised to the family during an in-person meeting earlier this year.
“We have also made significant improvements to our obstetrics services since this tragic event by introducing robust administration and workforce improvements, including recruitment to a full team of eight consultants.
“We only now use regular locum staff, who are very familiar with our service, and these staff are supported by a locum induction and orientation guide that has been established with the assistance of a regular highly-experienced locum.”
Steps had been taken to improve communications with patients who experience loss, including the implementation of a separate wait list to arrange follow-up appointments with clinical staff in a timely manner, he said.
The Commissioner recommended Health NZ provide an update to HDC on the effectiveness of the changes it has made to its obstetric service within three months of the date of the report.
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.