A newborn baby boy was struggling to breathe for two hours before a midwife left him in a hospital corridor with family but without any medical supervision while she sought help.

Deputy Health and Disability Commissioner Rose Wall has criticised the midwife's decision to leave the baby in the corridor, saying hospital midwives or a paediatrician should have been called immediately and the baby should never have been without medical supervision.

The baby was later diagnosed with meconium aspiration syndrome - a condition where a newborn suffers trouble breathing due to inhaling a dark green, sterile fecal material called meconium into the lungs before or around the time of birth.

After additional medical support, the baby was transferred to a highly specialised hospital for care for an extended period of time.


The midwife has been found in breach of the Code of Health and Disability Services Consumers' Rights for the care she provided to a newborn baby with respiratory distress, an HDC report has today revealed.

The midwife in breach was a Lead Maternity Carer (LMC) - who co-ordinated the mother and baby's care independently throughout the pregnancy, rather than a hospital midwife who may be a different person each time.

Wall recommended the Midwifery Council of New Zealand conduct a review of the midwife's competence, should she wish to return to practice, and that she apologise to the boy's mother.

The Deputy Commissioner also recommended that the DHB, which was not named in the report, considered how its relationships with LMC midwives could be improved, and whether it was clear to LMC midwives that the resuscitaire was not to be used in the corridor.

In the report, the DHB said this was an opportunity for the DHB to work with its core
midwives to reflect on the professional relationships between core midwives and LMC
midwives to ensure good communication at all times.

Following delivery, at a public hospital, the baby showed signs of respiratory distress and the midwife observed meconium in the birthing pool and on the placenta.

The midwife did not seek assistance from the hospital midwives or a paediatrician over a two hour period.

When the baby deteriorated further, she moved him to a resuscitaire in the corridor where she left him with family members, without medical supervision, while she sought assistance, the report said.


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"This on reflection was not a good move," the midwife said in the report.

In the report, the Midwifery Council told HDC: "The current situation is that [the midwife] remains under a [competence review] order but has not practised since 2018 when she voluntarily relinquished her practising certificate, owing to fitness to practise concerns.

"[The midwife's] practising certificate will not be reinstated until the concerns around her fitness to practise have been addressed."

The midwife told HDC she had apologised to the mother and her family directly over the course of the postnatal care and did not consider that a formal written apology at this stage is necessary.

The midwife also told HDC that she did her best in the circumstances, and she trusted that her decision to leave practice would provide some reassurance to the boy's mum.

"[T]he events also exposed a cultural issue and some systems failures in the maternity
unit, which can make LMC's vulnerable as some individuals do not work in a collegial
manner," the midwife also said in the report.