The 25-year-old woman, who was pregnant with her third child, was admitted to hospital 10 days after her due date. She met with her lead maternity carer midwife and was assessed by the on-call registrar. The baby was noted to be in a face presentation.
Once induced the baby's position did not change and it was decided, an hour or so after administering Syntocinon (a drug that induces labour) that a caesarean section was needed.
Midwives had difficulty detecting and recording the fetal heart rate but this was not adequately communicated and the heart rate was not monitored again on arrival in theatre.
After the anaesthetist had inserted a spinal block the registrar realised the fetal heart rate was not being monitored. The registrar performed an ultrasound scan and confirmed that no fetal heartbeat was present.
After discussion with the parents, a caesarean section was done and the baby was stillborn.
"This case was an example of the Swiss cheese effect," said Dr Jenny Westgate, a consultant obstetrician called in to advise the investigation.
"No one error by one person was the cause but rather different errors by different people all contributed to the eventual sad outcome.
Mr Hill found it was clinically inappropriate and contrary to the health board's policy to commence Syntocinon in the circumstances, and that the registrar should have consulted with the on-call consultant before making the decision.
He also found the registrar failed to provide the woman with adequate information about her options and shared responsibility for the failure to monitor the fetal heart rate in theatre.
The registrar was criticised for the failure to perform an emergency caesarean immediately when the fetal heartbeat was not detected.
Mobile users click here to read report
"Policies and procedures are of little use unless they are both accessible to staff and followed consistently. I am satisfied that the policies were available to staff. However, despite this I am concerned that the policies were not followed by both the registrar and the midwife," Mr Hill found.
Mr Hill said staff did not think critically, important information was not communicated effectively and the health board should accept some responsibility for the registrar's decision-making.
The health board's Service Manager for Woman Child and Family, Donna Mayes, said this was a sad and tragic case for everyone involved.
"Lakes DHB is mindful of how difficult this has been and extends its deepest sympathy to the family."
Ms Mayes said the case showed the complex nature of clinical practice where despite best efforts, clinical decisions could have unexpected and sometimes tragic outcomes.
She said as a result of the board's review at the time, several changes had been made to try to eliminate the chance of something like this happening again.
A framework for clinical communication has also been rolled out which gives staff prompts about what information about a patient needs to be handed over to another health professional and to ensure nothing has been missed.
It is now mandatory for a baby monitoring machine to be attached to a mother during the preparation for a caesarean, , she said.
"This case is being used for education purposes and is shared with new staff to generate discussion about using policies and guidelines effectively to support their practice and about asking other clinicians for their view when situations deviate from the 'norm'," the health board statement said.
In line with the recommendations, all caesareans at Rotorua Hospital will be audited for the next 12 months and after that there will be regular random audits. Compliance is being monitored and reported to the commissioner.
The Rotorua Daily Post asked the health board whether the registrar involved was still employed at Rotorua Hospital however it did not respond.
