Source: Radio New Zealand
Unsplash / RNZ composite
A slightly premature baby who died while the nurse caring for him was on a break should have been checked while she was away, an investigation has found.
The Health and Disability Commissioner report said the case highlighted the challenges of caring for late pre-term babies, those born between 34 and 36 weeks who often appeared healthy but faced increased risks.
The baby boy died at Auckland City Hospital, two days after he was born by a “semi-urgent” caesarean at 35 weeks, three days gestation.
His mother made a complaint to the commissioner, saying his care felt hurried, lacked empathy, and staff did not take her concerns seriously enough.
A feeding tube had also been put in without her consent, she said.
After 17 hours in the maternal complex care area, the baby was moved to a post-natal ward with his mother, rather than the neonatal intensive care unit(NICU).
He was having trouble feeding, and had a tube going from his mouth to his stomach. He was jaundiced and was being monitored for neonatal abstinence syndrome because his mother had been on opioids for a pain disorder.
He had been vomiting but his mother and medical staff disagreed on how much.
On the night the baby boy died, the nurse caring for him went on a one hour meal break and when she checked on him on her return, he had vomited heavily and was not breathing.
He could not be revived.
The nurse told the commissioner that when she left she told the midwives on the ward to check on the baby, however the midwives said she told them none of her patients needed anything while she was way.
Health NZ said, either way, it would not have been usual practice to check the baby hourly, and if he had needed very close monitoring he would have been in the NICU.
Deputy Commissioner Rose Wall said she extended her sympathies to baby A’s whānau for their extremely tragic loss and that the serious complaint needed to be carefully looked at.
Deputy Commissioner Rose Wall. LANCE LAWSON / SUPPLIED
An expert nurse who reviewed the case found the baby should have been checked at least once during the nurse’s break as “he was in an incubator under lights, he had an orogastric tube, he was premature, he was being observed for opioid withdrawal and his mother was sleeping heavily”, the report said.
There was also a breakdown in communication between staff and the baby’s mother about the feeding tube and more should have been done to inform her about why it was needed, the nurse said.
An expert doctor found the baby had been cared for and monitored appropriately by medical staff.
The commissioner agreed, saying the baby’s symptoms were monitored and managed appropriately.
But it found his patient rights had been breached by the failure to check on him during the nurse’s break and the “apparent lack of team work” between nurses and midwives on that shift.
“The investigation has highlighted the unique challenges of managing late pre-term infants postnatally and the importance of a team approach to care,” Wall’s report said.
Auckland City Hospital now had a transitional unit for late pre-term babies, as well as those who are being transferred from the NICU.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
