Coroner Gary Evans yesterday said he may consider it his duty to recommend a change to the law where hospital-contracted midwives and independent midwives must adhere to the same protocols and guidelines.
Mr Evans was speaking at the second day of an inquest into the death of a baby boy who died shortly after birth at Wanganui Hospital. Mr Evans felt it was his coronial duty to make recommendations to government to change the independent health practitioners' access agreements with their district health boards.
In this particular instance with the Whanganui District Health Board, it could well be warranted, he said.
The inquest was into the death of Melissa Brider's first child, Tane O'Hagan-Brider, on December 3, 2004. The child died not long after he was born.
Ms Brider accused her midwife Cheryl Baker, an independent midwife, of not listening, and ignoring her when she first voiced concerns over Tane's condition.
Wanganui Hospital head of midwifery Lenna Young told the hearing that standard practice at the maternity unit ensured there was a midwife rostered to work and be available in the delivery suite for each eight-hour shift.
"This cover was provided by the DHB 24 hours a day, seven days a week," she said.
It was an unwritten guideline for midwives or anyone involved in maternity care, that wherever possible there were two birth attendants at every birth. This was so one could take care of the baby and one could look after the mother, she said.
However Ms Baker, the Lead Maternity Carer (LMC) was alone at Tane's birth and had not called another midwife in, she said.
Mr Evans asked if she had called another midwife in, would that have meant she had to share the fee.
"No, definitely not ... it's just good practice to have a second midwife there, it always had been. It's an unwritten guideline here."
However, there were no clinical policies or guidelines that covered how many birth attendants should be at a birth, Mrs Young said.
Tane's father, Robert O'Hagan, said when his son was born there was obviously something very wrong.
"He was a dark grey purplish colour, he wasn't moving and he was breathing, he was wheezing trying to breath."
Mr O'Hagan said Ms Baker left the room and said she would come back with a doctor.
Mrs Young said if there had been two birth attendants, one could have gone for help while the other one stayed.
At the time of Tane's death there was no policy or guideline with a recommendation on the length of time a midwife should spend observing mother and baby after birth, Mrs Young said.
"But there has subsequently been a guideline where 30 minutes is the recommended time."
Another issue was the systemic call bell failure.
Mrs Young said this was because it was the old hospital and not everything was in perfect working order.
One bell could only be heard in the delivery office as long as someone was there, the staff bell would be heard quietly in the other part of the maternity unit a hallway away, and to sound the emergency bell where strobe lights came on and an alarm sounded you had to leave the room and press a red button in the hallway.
It would sound the alarm throughout the hospital, she said.
As it was, it took three calls to get staff up to the resuscitation unit in the delivery unit.
Registered nurse Kim Tennent said she had rushed to the delivery suite from the maternity ward.
She said baby Tane was a "funny dark colour".
"He didn't look great and he made a funny noise, a gasping strange noise. I kept waiting for him to cry."
Ms Tennent said she rang the doctor but no one came and she had to keep ringing them.
"Then I called neonatal and said 'help, we have a flat baby'."
The neonatal and ICU nurses eventually came, she said
Ms Brider was sobbing at the back of the room as she listened to what had happened.
Ms Tennent said at the same time, there was no one looking after the mothers and babies and post-op care patients in the other ward, and she was the only one on.
"And we couldn't get hold of the house surgeon."