A district health board has been found to have breached the health code for the care provided to a pregnant woman with diabetes who delivered a stillborn baby after an emergency caesarean.

Health and Disability Commissioner Anthony Hill made several recommendations to the MidCentral District Health Board in finding it in breach of the code, including a review of policies and protocols and reviewing training procedures.

A woman in her thirties with Type 1 diabetes arrived at a hospital emergency department with a headache, nausea and general illness when she was 31 weeks pregnant.

She was sent directly to the maternity unit without being triaged in the emergency department. The woman told staff she had diabetes and that she was under specialist care, but the providers of her care were not advised of her admission to hospital.


The woman was given intravenous fluids, and her condition improved overnight and she was discharged the next day.

She then become unwell again, and returned to the emergency department early the next morning.

Given the woman's life-threatening condition, an emergency caesarean was performed and a stillborn baby was delivered.

Hill said the DHB team had enough information to give the woman appropriate care, but judgment and communication failure meant it did not do so.

He said the signs and symptoms she might expect to experience were not communicated to her adequately, her care service was not contacted when she presented to the emergency department and various tests were not done.

Names in the commissioner's report had been removed - except MidCentral DHB - to protect privacy.