List of errors led to death
A baby in Whanganui died just after childbirth because those caring for the woman in labour failed to realise the boy was in distress, equipment failed and systems were broken, the Health and Disability Commission has found.
In a decision released yesterday, Deputy Health and Disability Commissioner Rose Wall said a delay in picking up that the baby boy had become distressed during labour in 2015 combined with a further delay in calling for specialist support by inexperienced midwives lead to fatal consequences.
The baby, who was not named and referred to as Baby A, was born not breathing and described as flat and white, and made no attempt to breathe, which indicated he had been in distress for some time, Wall said.
He later died in intensive care. Wall was critical of the care given to the woman while in labour, which included:
The core midwives failed to advocate for the adequate monitoring of the boy’s fetal heart rate, and failed to recognise and respond to fetal distress
Whanganui District Health Board staff failed to call the paediatrician before Baby A’s delivery and, when they did attempt to call him, they called the wrong number
■ The staff assist bell was pushed instead of the emergency bell when emergency assistance was required
■ The Whanganui DHB switchboard failed to make contact with the paediatrician or to leave him a message
■ The equipment required for an emergency resuscitation in the delivery room was not fit for immediate use
■ The ventilator was set up incorrectly.
Wall found the Whanganui DHB in breach of the Code of Health and Disability Services Consumers’ Rights in failing to provide reasonable skill and care to the mother, Mrs A, and Baby A.
Wall’s recommendations included asking the Midwifery Council of New Zealand to review the competence of both midwives involved, letters of apology from both midwives to Mrs A and her family for breaching the code, and asking the Whanganui DHB to provide a report on its communication systems for maternity emergencies and the frequency of the fetal surveillance education provided to staff and lead maternity carers.