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Source: Health and Disability Commissioner
Basic omissions in the care provided to an otherwise healthy infant can have extremely serious consequences.
Birthcare Auckland Limited (Birthcare) and a registered midwife have both been found in breach of the Code of Health & Disability Services Consumers’ Rights (the Code) for failing to deliver services with reasonable care and skill to a vulnerable infant following his birth. 
There were also serious shortcomings in Birthcare’s subsequent management of the adverse event and in their response to the parents’ complaint. As a result of the significant failings identified in this case, Birthcare and a midwife have been referred to the Director of Proceedings to decide whether proceedings should be taken.
The infant was born healthy at Birthcare, but in the 24 to 48 hours following his birth, his healthy presentation slowly declined as he developed hypoglycaemia (low levels of sugar in the blood).
A delay in identifying and treating the hypoglycaemia resulted in the infant going into respiratory and cardiac arrest requiring resuscitation during an ambulance transfer to the public hospital’s neonatal intensive care unit (NICU).
The infant now has cerebral palsy with significant developmental delays and the family faces ongoing uncertainty around the extent of harm and the impact it will have on his future development.
Several Birthcare midwives demonstrated shortcomings in the provision of care, however, the midwife caring for the infant over the critical period should have recognised and responded appropriately to the troubling clinical picture as it was emerging.
Careful consideration of all of the infant’s symptoms should have alerted the midwife to the seriousness of the situation and led her to investigate further, by way of a full assessment and then intervention. This did not occur. The midwife demonstrated inadequate independent clinical decision-making at key points.
Deputy Health and Disability Commissioner Rose Wall found Birthcare and the registered midwife in breach of Right 4(1) of the Code, which states every consumer has the right to services provided with reasonable care and skill. 
The midwife was found to have not appropriately managed the infant’s hypoglycaemia, or taken appropriate actions in recording vital signs prior to the ambulance transfer or administering oxygen during the ambulance transfer.
Ms Wall says, “The registered midwife did not follow the correct basic life support protocols required in an emergency situation such as this. The infant was in respiratory and cardiac arrest. Chest compressions should have been initiated promptly.”
In the context of treating hypoglycaemia, Ms Wall said the Birthcare policy on neonatal hypoglycaemia was not consistently well understood by staff.
While hypoglycaemia and its management are within a midwife’s scope of practice, it is incumbent on providers, like Birthcare, to ensure its staff are aware of the particular requirements of its own policies to maintain a consistent standard of care, Ms Wall said.
Ms Wall noted that because no one at Birthcare administered the infant dextrose gel when he was hypoglycaemic, there was a fundamental failure to deliver services to a vulnerable infant with care and skill. 
Ms Wall found Birthcare breached Right 10 of the Code for their poor handling and management of the adverse event and the parents’ subsequent complaint. Right 10 gives consumers the right to complain about a provider in any form appropriate to them and the provider must facilitate a fair, simple, speedy and efficient resolution of complaints.
Additionally, Ms Wall also found Birthcare in breach of Right 5(2) of the Code for failing to communicate openly, honestly and effectively with the parents about the complaint, and Right 6(1) of the Code for failing to openly disclose that the adverse event was being reviewed.
Ms Wall made a number of recommendations, including:
– That Birthcare and the midwife provide written apologies to the infant and his parents for the deficiencies identified in the report.
– That Birthcare provide HDC with evidence of staff training in documentation of handover and escalation, emergency skills, and roles and responsibilities during ambulance transfers.
– That Birthcare update its Reportable Events Policy to include consumer participation as a key principle, and implement this as a meaningful part of its reportable events process.
– That two of the midwives involved in the adverse event and complaint management each provide a personal letter of apology to the parents for their unprofessional communications, and that current Birthcare senior staff upskill in complaint management. 
Names have been removed from the report to protect privacy of the individuals involved in this case.
The Commissioner will usually name providers and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. More information for the media, including HDC’s naming policy and why we don’t comment on complaints, can be found on our website here.
In 2021/22 HDC made 402 recommendations for quality improvement and providers complied with 98% of those recommendations.