Health board ‘failed mum and baby’
The family of a child who died as a result of inadequate care at birth will receive a written apology from the obstetrician.
The baby died after it was delivered by emergency Caesarean section in 2015 suffering from a brain injury and in ‘‘poor condition’’, the day after a registered midwife noted a variable foetal heart rate when the mother was admitted to hospital.
A report published by the Health and Disability Commissioner yesterday found staff at the district health board (DHB) responsible for the mother and child failed to provide ‘‘reasonable care and skill’’.
Deputy Commissioner Rose Wall said the obstetrician failed in his responsibilities, incorrectly interpreted the foetal monitor and did not tell the mother a C-section was ‘‘the only appropriate course of action’’.
It had been two years since the mother had delivered her first baby by emergency C-section after a failed forceps delivery. She had voiced a desire for a natural birth.
Because of these ‘‘very strong preferences’’, the obstetrician offered both a C-section and to induce labour.
The obstetrician monitored mother and baby throughout the day. By evening, the baby’s heart rate had dropped and obstetrician began to induce labour.
‘‘His plan was to stop cardiotocography (CTG) monitoring to allow the woman to mobilise, and for another CTG to be commenced at 10pm.’’
The obstetrician went home and asked to be called back for the planned monitoring, but the request was never documented and he was not called. Four midwives failed to comply with DHB guidelines, Wall said. ‘‘There was a concerning delay in delivery of the baby. The DHB should have had in place ... a culture that supported staff to voice concerns and ask questions.’’
The next morning when the baby was monitored via CTG the outcome was ‘‘nonreassuring’’. the The obstetrician was called to review her, arriving at 4am. Forty minutes later, he ruptured the woman’s membranes. The fluid showed signs of foetal distress.
At 5.20am the woman had an emergency C-section and the baby was delivered at 6.55am – the baby had no heartbeat and was not breathing, but was resuscitated.
The baby was diagnosed with multiple brain injuries and later died.
It was recommended the obstetrician write to apologise; and that the DHB update the commissioner on increasing the number of obstetricians at the hospital, consider developing policies around foetal surveillance, and use the case for staff training.