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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Rose Wall today released a report finding a District Health Board, a self-employed midwife and a paediatric registrar in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for the care provided to a woman in labour and to her baby following birth.
The woman arrived at the hospital in spontaneous labour at term with her first baby under the care of her Lead Maternity Carer (LMC), a self-employed midwife. After several hours of labour she was mistakenly assessed as having progressed to the second stage with some signs of fetal distress. It was unclear to the LMC midwife as to who was responsible for managing the labour from that time. After pushing for nearly two hours it was recognised that the vaginal wall had been mistaken for the fetal head and the woman’s cervix was only 6cm dilated. The labour continued but further signs of fetal distress were not reported to the obstetrician. The baby was delivered by caesarean section requiring resuscitation. The baby was very unwell and required intensive treatment. The care was suboptimal in some points, including a significant drug error. Tragically the baby died within 24 hours of birth.
Ms Wall found a number of omissions in the woman’s care and was critical of the midwife’s lack of clarity regarding her ongoing role and the handover to secondary care. Ms Wall said that the LMC midwife’s lack of clarity and aspects of the system in place at the DHB contributed to the omissions. Criticism was made of a paediatric registrar who administered an incorrect dose of midazolam to the baby and of the DHB systems for several aspects of sub-standard care provided to the baby.
Recommendations were made and the DHB developed guidelines that set out the transfer process from primary to secondary maternity care at the hospital and a new sticker to standardise documentation of CTG interpretation. The LMC midwife undertook a number of actions to meet the requirements of the Midwifery Council competence programme. The DHB, LMC, and the paediatric registrar were all asked to provide written apologies to the family.
The full report for case 
C17HDC01543    is available on the HDC website.