According to a decision from deputy Health and Disability Commissioner (HDC) Rose Wall released today, evidence of the Bay of Plenty midwife was disputed while Wall took aim at her inadequate note-taking and general care for the patient.
The decision says the woman, referred to as Ms A, moved to the Bay of Plenty while 31 weeks pregnant to be closer to family. She was transferred to the care of a local midwife identified only as Ms B.
The woman had been told by her previous midwife she needed a further ultrasound scan when she arrived in the region, and she says she repeatedly asked her new midwife to book this.
The midwife told the HDC that around a week and a half later, she faxed a handwritten referral for an ultrasound to Whakatāne Hospital. Neither the midwife or the hospital could provide the document or evidence that it was sent or received.
Before the supposed referral was processed, the woman presented to the hospital’s emergency department suffering from vomiting, dehydration and tingling in her arms and legs.
The woman had met with her midwife earlier in the day, and she provided the ED with a letter written by her midwife outlining her health issues.
Blood, urine and faecal tests were taken and the woman was discharged around three hours after first being seen. She was not seen by an obstetrician or taken to the maternal ward during the visit. Medical staff deemed the issue was infectious diarrhoea and carpal tunnel syndrome.
The faecal test result came back three days later, showing the woman was suffering from campylobacter gastroenteritis. Results weren’t shared with the midwife, but the notes show the hospital confirming they’d sent the results to the woman’s GP. Those same notes stated the woman didn’t currently have a GP.
Three days after that, the woman met with her midwife. The midwife recorded the baby’s movements as active, although there were no notes showing the patient’s ED presentation was discussed.
The lack of an obstetrician appointment for a further scan was raised by the woman. The midwife said she had contacted the hospital to query this and was told there was no record of the woman in the system.
The hospital told the HDC that they had no record of the midwife calling on this date.
At some point over the following days, the midwife typed a referral letter and hand-delivered it to the hospital. The referral was processed by the hospital almost immediately the next day. The woman was to be seen within ten days.
The appointment never eventuated. A week after the referral was actioned, the woman’s membranes ruptured. She gave birth to a stillborn baby the next day.
The woman was discharged three days later and says the midwife attended the baby’s tangi and visited her a week after that, but never again returned to check on her.
The midwife’s notes say she’d make six post-natal visits, but told HDC that three or four of those times the woman was not home or didn’t answer the door.
Care in breach of patient rights - HDC
Deputy commissioner Rose Wall found that the midwife failed to provide sufficient and timely care to ensure the woman saw an obstetrician. She found, on the balance of probabilities, the supposed initial hand-written referral fax was never sent.
While accepting the local health system posed difficulties for midwives, “[the midwife] was aware of this system, and it was her responsibility in the circumstances to proactively follow up on matters.”
When it came to post-natal care, Wall was “very critical”. Of the supposed six home visits, there was no documentation or notes taken.
“In light of [the midwife’s] differing recollections and lack of documentation to support her version of events, I prefer the evidence of Ms A. I consider it more likely than not that there was only one postnatal visit, not six.”
Finally, Wall criticised the midwife’s record keeping, writing in her decision that documentation was “severely lacking”. The midwife was found in breach of two sections of the code of patient rights.
She recommended the midwife write a letter of apology, update the HDC with training she has undertaken, and undertake an audit of the previous three-month period to ensure all communication has been documented adequately.
The Midwifery Council previously ordered the midwife to undertake a competence programme.
When it came to the Bay of Plenty DHB (now Te Whatu Ora), Wall said she was concerned by the hospital not alerting the woman’s midwife nor arranging an obstetrician appointment upon learning of the campylobacter infection. Te Whatu Ora was found in breach of the code of patient rights.
It too was recommended to write a letter of apology to the woman, as well as a review of communication and access to clinical records for outside providers such as midwives.
