“When our baby was being resuscitated and worked on … no one communicated to us what was happening.”
The Human Rights Review Tribunal has issued a declaration that registered midwife Korina Burne-Vaughn breached the Code of Health and Disability Services Consumers’ Rights.
The case was referred to the Human Rights Review Tribunal following the findings of an earlier complaint by the baby’s grandmother to the Health and Disability Commissioner.
Particularly, the tribunal’s declaration said Burne-Vaughn failed to provide services to the mother with reasonable care and skill; failed to provide services that complied with legal, professional, ethical, and other standards; and failed to provide information that a reasonable consumer would expect to receive.
Burne-Vaughn has acknowledged that her conduct during the later stages of the woman’s pregnancy and around the birth was in breach of the code.
She accepted that she did not order a 28-week blood test for the mother, did not follow up on the results of the 29-week ultrasound scan, and visited the mother less frequently than required.
She accepted that her care and management of mother and baby during labour was inadequate, and she failed to regularly monitor and record fetal and maternal observations according to expected guidelines.
She also accepted that her management of the resuscitation was inadequate and delayed.
She failed to assemble the necessary resuscitation equipment before the birth.
In an agreed summary of facts attached to the tribunal decision, Burne-Vaughn accepted that while initially her focus was on the resuscitation and the trauma and stress involved, she failed to communicate that the baby had been stillborn.
This led the family to believe that he was born alive and subsequently died during the resuscitation attempts.
“The [mother] had no knowledge that her baby had not taken a breath and did not have a heartbeat at the time of his birth,” the summary said.
“The whānau assumed their baby had lived then died on the [resuscitation] table because no one communicated to them otherwise.
“They found out that it was a stillbirth four days later from hospital midwifery staff.”
The family had earlier complained to the Health and Disability Commissioner about the delivery, which happened at Birthcare Huntly, a service which has since closed.
In that complaint, the whānau spoke of the distress and disbelief not only of losing their baby, but also of navigating the process following a stillbirth.
They said they were hurt and confused when they discovered Burne-Vaughn had filled out a medical certificate incorrectly, recording that their baby was born at 10.30am on the day of delivery and the time of death was 11.18am.
“This caused the whānau to believe their baby had lived then died, only to discover later that he was stillborn and had never taken a breath.”
A review of the events by an expert adviser says Burne-Vaughn should have begun resuscitation within a minute of the delivery.
Instead, she provided stimulation by rubbing the baby for about six minutes before the arrival of other midwives and resuscitation attempts began.
After being discharged home, and following a night of pain and high temperatures, the mother was taken to hospital by ambulance and diagnosed there with postnatal sepsis, a urinary tract infection, and pregnancy-induced hypertension.
She underwent surgery to repair a second-degree perineal tear which had “not [been] sutured and [was] infected”.
The mother remained in hospital for four days, during which she was given an iron infusion for anaemia.
Burne-Vaughn has provided a written apology to the mother and her whānau.
She has also undergone a competence review by the Midwifery Council of New Zealand and completed an education programme and professional supervision.
Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.
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