Deputy Health and Disability Commissioner Rose Wall accepted there were complications, but found the DHB failed the woman on multiple points and ordered it to apologise to her.
She also recommended the DHB train staff on the management and monitoring of hypertension and pre-eclampsia in twin pregnancies, and provide the HDC with a copy of its cultural/kaupapa training framework.
The woman, who was a smoker and aged in her 30s, already had children and was pregnant with her twins in 2019.
However, during her pregnancy she developed complications, including chronic hypertension, pre-eclamptic toxaemia [PET], and intrauterine growth restriction [IUGR] and required regular monitoring at the high-risk antenatal clinic.
She was admitted into Waikato Hospital on April 29 for the babies to be monitored, as one had an unusual heart rate.
On May 13 a cardiotocography confirmed there was no fetal heartbeat for one of the twins.
She then hemorrhaged and had an emergency c-section. Only one of the twins survived.
The woman said during her time in hospital she repeatedly asked to have her twins delivered early but was told it couldn’t happen due to staff shortages.
However, the woman said she stayed in there “against my will ... for nearly three weeks listening and co-operating with every medical advice given when it concerned my babies and still, when I felt her die, no one listened.
“No one listened to me the night before, I felt my baby die inside of me.”
After being told her baby had died, she needed to ensure that her babies were taken care of but her cultural need for family to greet and care for the babies was ignored.
In response to her cultural concerns, Te Whatu Ora said the medical and midwifery team were all genuinely concerned and tried their best to provide support and encouraged whānau to be with her at all times.
After the c-section, her medical team supported the whānau’s request for karakia while she was in the Intensive Care Unit [ICU].
ICU staff arranged for her daughter to be beside her in a cooling cot.
Te Whatu Ora had since made numerous changes and “sincerely regrets failing to provide an appropriate standard of care”.
Wall said after the woman’s “complicated” c-section, “for the most part the cultural support appears to have been appropriate”.
However, had her cultural needs “been assessed and appropriate support options put in place earlier, she may not have been left feeling so powerless, with the sense that her concern for her unborn children had not been heard.
“She would not have felt that she was left to manage her own spiritual needs and those of her babies following the loss of [baby].”
Wall found Waikato DHB breached Right 4(1) of the Code, which gives consumers the right to have services provided with reasonable care and skill.
She accepted the circumstances were challenging, but the cumulative deficiencies in the care provided amounted to the breach.
She was critical of Waikato DHB’s care following the first ED review when an effective plan was not put in place to closely monitor the woman’s condition in the community. She was also critical that medical input was not sought when two separate heartbeats could not be identified clearly, and of the decision over whether to deliver the babies early.
Wall recommended Te Whatu Ora Waikato provide a written apology, train staff on the management and monitoring of hypertension and pre-eclampsia in twin pregnancies, and provide HDC with a copy of its cultural/kaupapa training framework, outlining how the practice of tikanga with patients and their whānau is developed with all hospital staff.
Belinda Feek is an Open Justice reporter based in Waikato. She has worked at NZME for eight years and been a journalist for 19.
