KEY POINTS:
Four midwives at Palmerston North Hospital failed to heed a mother's concerns before her baby suffered neurological damage, the Health and Disability Commissioner has found.
Commissioner Ron Paterson said in a report released yesterday that "Baby A" was born in apparently normal condition in July 2003.
But three
days later he developed hypoglycaemia, or low blood glucose concentration, and he sustained "significant neurological damage" as a result.
It was generally accepted that healthy full-term newborns, breastfeeding on demand, did not need to have their blood glucose routinely checked.
But hypoglycaemia was one of several conditions that must be assessed and monitored during the first few days of life, Mr Paterson said.
He said a general issue raised by the case was the apparent failure of the midwives to listen carefully to what the mother was telling them.
"Providers should always treat consumers with respect and listen carefully to their concerns."
Two days after Baby A was born he developed jaundice and was placed under phototherapy lights.
Next day his temperature dropped, he was reluctant to feed and had developed jittery movements - all signs of developing hypoglycaemia.
Although the four midwives who cared for the baby at different times recorded the timing of his feeds and passing of urine and stools, they did not routinely record the duration or quality of his feeds, nor the colour and consistency of his stools.
Thorough documentation may have alerted staff to his decreased feeding and increased sleepiness and helped oncoming staff to better plan his care and management.
"The documentation in this case was not sufficient to ensure all the necessary information was available to the midwifery staff caring for Baby A, and this may well have contributed to his deteriorating condition," Mr Paterson said.
He found all four midwives failed to meet professional standards of documentation, so breached the health and disability services code.
He also found that MidCentral District Health Board breached the code because documentation systems in its maternity unit fell below the standard expected and put patients at risk.
But Mr Paterson commended the DHB for actions taken in light of the case to improve its maternity service, and recommended that one of the midwives write to Baby A's parents to apologise for her breach of the code.
Among the changes introduced at the maternity unit were breastfeeding charts that included assessment of infants' feeding on arrival and prompts to record stool and urine output; and documented care plans for mother and baby.
- NZPA
