District health board, hospital staff and midwives failed mother in labour, newborn

The Health and Disability Commissioner's report found a delay in picking up the baby had become distressed, and in calling for obstetric and paediatric support.Photo / 123RF

The care provided by two midwives, hospital staff and the Whanganui District Health Board has been slammed following the death of a newborn in 2015.

A report by the deputy Health and Disability Commissioner Rose Wall found a woman and her newborn baby were not provided adequate care during labour.

The mother booked in a self-employed midwife as her Lead Maternity Carer (LMC).

During the labour process, the midwife failed to monitor the baby's heart rate sufficiently. When the LMC had difficulty managing the labour, assistance was provided by hospital-employed midwives.

"However, there was a delay in picking up that the baby had become distressed and in calling for obstetric and paediatric support," Wall's report said.

"The baby was born not breathing and later passed away in intensive care."

At 9.06pm, around seven hours after going into labour, the fetal heart rate (FHR) was recorded and the hospital midwife said she was struggling to hear the FHR.

The labour continued but the midwives continued to struggle to hear the FHR. The baby was born at 10.10pm "white and floppy" and was not breathing.

Following failed resuscitation attempts, a transfer to a second hospital and being put in intensive care, the newborn later died surrounded by his family.

A review found the LMC midwife failed to provide the mother and newborn with services of reasonable skill and care. The LMC breached the Code of Health and Disability Services to Consumers' Rights, Wall said.

Meanwhile, the hospital midwife was also found to have breached the Code. The midwife had a responsibility to advocate for adequate monitoring of the FHR and should have noticed the fetal distress, Wall added.

Failures were also found in the care, communication system and emergency equipment at Whanganui DHB. They too were in breach of the Code.

The Ministry of Health was advised it would be provided with a copy of her report to take into account the findings for its ongoing review of maternity services.

Names were removed, except the Whanganui DHB, from the report to protect the privacy of those involved.

The deputy commissioner recommended the following:

• That the Midwifery Council of New Zealand consider whether any further review of the LMC midwife's competence is required;

• The hospital midwife apply to return to practice and the Midwifery Council of New Zealand consider whether a competence review was warranted;

• Both midwives write an apology to the woman and her family for the breaches;

• The DHB report to the HDC on its communication systems for maternity emergencies and the frequency of the fetal surveillance education being provided to its staff and to self-employed lead maternity carers.

A Whanganui District Health Board spokesman said the DHB acknowledged the findings.

"We express our deep regret at what happened in January 2016 and the mistakes which culminated in the loss of a newborn baby. We again extend our profound condolences and apologies for the deficits in the care we provided to the family involved.

"As a result of the incident and our subsequent inquiries into it, a number of changes have been made around maternity and paediatric care at Whanganui Hospital."

The changes included:

• The step-by-step guide to the neonatal ventilator has been revised.

• In the event of an emergency, a second consultant paediatrician is called.

• Regular neonatal training sessions are now conducted within the Whanganui DHB.

• A full training session in ventilation and therapeutic cooling was conducted.

• All calls between the lead maternity carer and core midwives regarding pending admissions are documented.

"We believe these changes will improve the care that women and babies receive in the maternity and paediatric services," the spokesman said.