{"id":564489,"date":"2026-08-10T08:00:20","date_gmt":"2026-08-10T08:00:20","guid":{"rendered":"https:\/\/www.newsbeep.com\/nz\/564489\/"},"modified":"2026-08-10T08:00:20","modified_gmt":"2026-08-10T08:00:20","slug":"hdc-finds-health-nz-lakes-district-failures-contributed-to-babys-brain-damage","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/nz\/564489\/","title":{"rendered":"HDC finds Health NZ Lakes District failures contributed to baby\u2019s brain damage"},"content":{"rendered":"

According to a report released today by HDC deputy \u200b\u200bRose Wall\u200b, the baby was born at Rotorua<\/a> Hospital by emergency caesarean section in 2023 after her mother developed pre-eclampsia. <\/p>\n

The day before the birth, the mother was started on labetalol, a beta-blocker used to treat high blood pressure.<\/p>\n

Under the hospital\u2019s neonatal hypoglycaemia guideline, babies exposed to beta-blockers are considered at risk of low blood sugar and should receive blood glucose monitoring shortly after birth. <\/p>\n

The investigation found the mother\u2019s labetalol prescription was not recorded in the baby\u2019s records, and therefore was not identified as a risk factor when planning the baby\u2019s ongoing care.<\/p>\n

Initially, the baby appeared healthy and breastfed well. However, the following day, nurses recorded she was sleepy, uninterested in feeding and would suckle briefly before falling asleep. <\/p>\n

The mother became increasingly concerned.<\/p>\n

She questioned whether her daughter was getting enough milk, asked for formula and raised concerns with staff several times throughout the day. <\/p>\n

At one point, a nurse recorded the mother\u2019s concern that \u201cno one [was] checking on baby\u201d. She was reassured that her daughter had been assessed and would be checked again before discharge. <\/p>\n

Despite the baby\u2019s ongoing feeding difficulties and increasing sleepiness, no blood glucose test was carried out. <\/p>\n

The HDC\u2019s report noted that abnormal feeding and lethargy were warning signs of hypoglycaemia under Health NZ\u2019s guideline and should have prompted blood glucose screening.<\/p>\n

However, staff had failed to recognise the signs as requiring further investigation, the report stated. <\/p>\n

About 9pm, just over a day after the baby was born, her condition deteriorated.<\/p>\n

A nurse noted she was \u201cfloppy\u201d and \u201cjittery\u201d and checked her blood sugar level. The result was 0.0 mmol\/L and a second test returned the same reading.<\/p>\n

An emergency call was made and dextrose gel was administered. An on-call doctor found the baby was experiencing seizures, had poor colour and poor respiratory effort.<\/p>\n

\"DeputyDeputy Health and Disability Commissioner Rose Wall has released a report into the incident. Photo \/ Health and Disability Commissioner<\/p>\n

She was transferred to Rotorua Hospital\u2019s special care baby unit and later to Waikato Hospital\u2019s neonatal intensive care unit. An MRI revealed severe brain damage likely caused by hypoglycaemia.<\/p>\n

Health NZ\u2019s adverse event review identified multiple shortcomings in the baby\u2019s care.<\/p>\n

The review found the mother\u2019s use of labetalol was not properly documented, staff failed to recognise poor feeding and sleepiness as signs of hypoglycaemia, and there was no process requiring parental concerns to be escalated for paediatric review. <\/p>\n

Deficiencies in forms, observation systems, staff training and workforce pressures were also identified.<\/p>\n

Health NZ accepted the baby \u201cmost likely would not have suffered the brain injury if a blood sugar level had been checked earlier\u201d. <\/p>\n

Wall found there had been several missed opportunities to identify the condition before the baby deteriorated. <\/p>\n

She found staff failed to recognise risk factors present from birth and symptoms that later developed. <\/p>\n

Wall was particularly critical of the response to the mother\u2019s concerns.<\/p>\n

\u201cI am also concerned that, although the RNs caring for [the mother] responded to her concerns about breastfeeding and whether [the baby] was being adequately fed, they did not appropriately escalate the matter, which meant no medical review of [the baby] was undertaken,\u201d she said in the report.<\/p>\n

While acknowledging the maternity service was operating under staffing pressures, Wall said Health NZ was responsible for ensuring staff had appropriate systems, documentation and training in place. <\/p>\n

She found Health NZ breached the Code of Health and Disability Services Consumers\u2019 Rights by failing to provide services with reasonable care and skill.<\/p>\n

According to the report, Health NZ has since implemented a range of changes, including:<\/p>\n

New newborn observation and escalation tools.Updated hypoglycaemia guidelines.Additional staff training aimed at recognising babies at risk of low blood sugar.<\/p>\n

Wall recommended that Health NZ provide a written apology to the family. She also sought an update from Health NZ\u2019s national chief midwife on steps being taken nationally to address ongoing midwifery workforce shortages.<\/p>\n

Tara Shaskey is an assistant editor and reporter for the Open Justice team. She joined NZME in 2022 and has worked as a journalist since 2014.<\/p>\n

Join the NZ Herald\u2019s Open Justice team for Case by Case<\/a>, a video and podcast series examining the disputes and decisions making headlines across New Zealand. <\/p>\n","protected":false},"excerpt":{"rendered":"According to a report released today by HDC deputy \u200b\u200bRose Wall\u200b, the baby was born at Rotorua Hospital…\n","protected":false},"author":2,"featured_media":564490,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10],"tags":[72157,1596,45034,22510,7557,43945,11424,11423,134,5365,111,139,69,61],"class_list":["post-564489","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health","tag-babys","tag-brain","tag-contributed","tag-damage","tag-district","tag-failures","tag-finds","tag-hdc","tag-health","tag-lakes","tag-new-zealand","tag-newzealand","tag-nz","tag-to"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/564489","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=564489"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/564489\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/564490"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=564489"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=564489"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=564489"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}