The baby was born late pre-term and died less than three days later. Photo / 123rf
A 50-hour-old baby who was born pre-term died while the nurse in charge of his care went on an hour-long break in the middle of the night.
When she came back from her break, the baby had vomited and was pale and despite intense efforts to resuscitate the boy, he couldn’t be saved.
Now, the Health and Disability Commissioner has found that the baby should have been checked during that crucial hour and that not doing so was a failure on the part of Health New Zealand Te Whatu Ora.
According to the facts of the investigation, the baby was born by caesarean section before he and his mother were transferred to the Maternal Complex Care area at Auckland City Hospital, because he was born late pre-term.
The baby had feeding problems and vomiting, an episode of respiratory distress thought to be due to nasal obstruction, a risk of neonatal abstinence syndrome (a condition that affects newborns who were exposed to opioids or addictive substances through the placenta during pregnancy) and jaundice.
A tube was inserted on the second day to deliver three-hourly feeds and other than vomiting after these feeds, a neurologist found that he was otherwise in normal condition.
During his first night, the baby was noted to have trouble feeding and breathing. Staff at the hospital removed the tube and his condition improved.
Two days post-birth, the baby’s condition continued to improve overall, according to the medical notes left by hospital staff. However, later that same evening, feeding issues resumed and a tube was reinserted.
At 12.15am on the morning of the third day, the registered nurse in charge of the baby went on a break and said she handed care over to two registered midwives and asked for the infant to be checked.
The midwives claimed that while the nurse told them she was going on break, she didn’t say anything about asking them to check on the baby.
The nurse checked on the baby when she returned from her break between 1.15am and 1.30am and found he was pale and had vomited, with the feeding tube sticking out of his mouth.
The nurse cleared his mouth, but he wasn’t breathing and couldn’t be resuscitated, despite the staff trying to revive him for 25 minutes.
Health NZ told the Health and Disability Commissioner (HDC) that neither midwife was at fault as the nurse hadn’t asked them to check on the baby while she was on her break.
Health NZ also said that it didn’t accept that the baby needed hourly checks because the clinical notes didn’t indicate any cause for concern and that letting babies sleep between checks was standard.
“Rounding is about popping in at regular intervals to see if mothers and babies need anything and if they are sleeping as expected, and are not due for assessments or feeds, they are not disturbed,” it said in response to the HDC’s investigation.
In addition, Health NZ said that if the nurse had any concerns about the baby, she would have checked on it immediately after taking her break.
“This would be normal practice on a postnatal ward and (for a normal-length break) any requirement for more regular monitoring would have elicited escalation for higher level neonatal care.”
The nurse was an experienced neonatal and maternity nurse and had worked at the hospital for a number of years, and Health NZ said that looking after a pre-term baby was well within her scope of expertise.
However, a nurse adviser to the HDC said that the baby should have been checked at least once during the hour-long break as he was in an incubator under lights, he had an orogastric tube, he was premature, he was being observed for opioid withdrawal and his mother was sleeping heavily.
Deputy Health and Disability Commissioner Rose Wall said the investigation highlighted the complex needs pre-term infants have postnatally and that it was a failure not to check on the baby for over an hour.
“While I accept that the policies in place at the time may not have required a baby on the ward to be checked hourly, Baby A was unsupervised for a period of longer than one hour, and irrespective of whether or not [the nurse] communicated the need for Baby A to be checked, by her own account, she thought that Baby A required a check while she was on her break,” Wall said.
“Accordingly, in these circumstances, I am critical that Baby A was not checked for over an hour while [the nurse] was on her break.”
Wall directed Health NZ to make an apology to the baby’s parents.
Health NZ said it now has a designated transitional care unit for pre-term babies, safety briefings are held at the beginning of each shift and there is a now a clinical midwife manager supervising every shift.
Neither the baby’s parents nor the attending nurse wanted to make any comments to the HDC.
Jeremy Wilkinson is an Open Justice reporter based in Manawatū, covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.