KEY POINTS:
A first-time mother died from severe bleeding during childbirth after blood was not put aside for her, despite her specific request.
Renee Bayliss died on January 26, within 4 1/2 hours of the birth of daughter Allix, who survived.
Auckland City Hospital has admitted that her death was
preventable.
Ms Bayliss was admitted to hospital on December 31 with pre-eclampsia, a serious condition that can involve high blood pressure. Her placenta was also found to be at risk of causing problems, including bleeding following birth.
Her partner, Nick Blackley, and his family this week gave the Weekend Herald a written statement summarising his own observations and hospital documents about Ms Bayliss' case.
Mr Blackley, a police officer, says Dr Denys Court, the hospital's clinical leader of women's health, told him at a meeting to discuss her care that his partner's death was preventable. This was reiterated in a letter to the family by chief medical officer Dr David Sage.
"Had different decisions been made by us," Dr Sage wrote, "we might have been able to stop the haemorrhage that caused her death.
"We acknowledge that coming to terms with the tragedy of Renee's death is made worse by the preventable element, and we apologise for the distress our actions have caused."
Mr Blackley said the risks of haemorrhage were known before the induction of Ms Bayliss' labour on January 24. Just as the induction process was starting, she had asked for cross-matched blood to be put aside for her.
Some hours later the blood bank advised the unit where Ms Bayliss was being treated that a manual cross-match was required and would take about an hour.
Allix was born about 3.30am on January 26 using a ventouse (suction device) and forceps. Ms Bayliss had lost about a litre of blood. This rose to 2.4 litres by 5.30am and continued.
Difficulties arose with the delivery of the placenta and she was taken to theatre for its removal at 5am.
Although a registrar had asked at 4.15am for cross-matched blood to be provided, the request was not carried out. The blood bank was not told a cross-match of blood was required until 5.20am. At 6.05am Ms Bayliss lost consciousness because of blood loss.
Twelve minutes later, "the first unit of blood was administered", followed by further transfusions. "This was about 32 hours after Renee had requested that 'blood be put aside for me'," Mr Blackley said.
The hysterectomy was not performed until some time after 7am. Ms Bayliss had suffered a cardiac arrest, CPR had been started and an emergency request was made for 15 units of emergency blood, the universal donor kind. CPR was stopped at 7.58am.
Dr Sage said last night the combination of circumstances in Ms Bayliss' situation was unusual and he was confident it was an isolated case. Key issues identified in her care were:
* Why she was not quickly given a transfusion of "universal donor blood", whose higher risks are considered justifiable, rather than having to wait for blood cross-matched because of particular antibodies that had been injected before the birth. The anti-D antibodies are given if there is a risk of the mother's immune system attacking the fetus' blood cells.
* Whether a hysterectomy, to stop the bleeding, should have been done sooner.
Dr Sage said a hospital investigation had led to changes in clinical policies, like the process for obtaining emergency blood, but the reasons for the events remained unclear, so he had commissioned an external review.
Deputy Health and Disability Commissioner Rae Lamb said her office had received a complaint but would not decide whether to hold a full investigation until the coroner's inquiry and the hospital's external review were completed.
