Using 0800 an issue in baby’s death — coroner

Mix of factors found to have contributed to newborn tragedy

Her life was only a few hours long, but she left a legacy of improved processes around critical care of newborns.

Evana-Jade Anarihi Iro-Tulikaki was born three weeks early on February 27, 2017, at Botany Downs Maternity Unit. She died at Auckland’s Middlemore Hospital eight hours and

25 minutes later.

While there was no clear answer about what medically caused her to die, there were issues that contributed to the “utterly tragic” outcome, a coroner has found.

They included aspects of her immediate post-natal care, and the halfhour it took to get an ambulance after maternity unit staff initially called the non-emergency 0800 number.

The circumstances could provide a valuable learning tool in midwifery training, in particular in the importance of following the set guidelines, Coroner Erin Woolley said.

She found a number of factors contributed to the baby girl’s death:

The initial temperature of the bath water, at 38C, was too hot; Evana-Jade may have got cold in the bath after birth;

Mother and baby were left alone in the first hour after birth during skinto-skin, contrary to Ministry of Health guidelines;

There were delays in calling an ambulance and when called, a nonurgent 0800 number was rung rather than 111;

It was not clearly conveyed to St John that there was a lifethreatening emergency situation.

After Evana-Jade was born, she was placed on her mother’s chest in a birthing pool at the unit.

They stayed there about 20 minutes before the mum moved on to a bed to deliver the placenta, still with Evana-Jade on her chest.

The lead maternity carer [LMC] then placed a hat on the baby and got a warm towel for her, and a blanket to put over the pair.

The midwife’s continued assessment of Evana-Jade’s position and colour revealed no cause for concern, so she left the room briefly to prepare a snack for the parents.

After that, when all appeared well, she left the room again to do paperwork. When the midwife returned, the parents expressed concern that Evana-Jade sounded “wheezy”.

The midwife discovered EvanaJade’s skin tone had paled dramatically, and that she appeared to be having trouble breathing.

Staff began resuscitation methods, and an ambulance was called using an

0800 professional healthcare line. Almost half an hour later, when no ambulance had arrived, the midwife dialled 111.

About 10 minutes later a neonatal team arrived and took Evana-Jade to Middlemore, where she was treated in emergency before being transferred to the Neonatal Intensive Care Unit in a critical condition.

Around midday, Evana-Jade’s parents were advised that further resuscitation efforts were futile. She died soon afterwards.

The post-mortem report noted Evana-Jade’s vulnerability due to her gestational age of 37 weeks. It gave two possible reasons for her sudden decline, including respiratory problems linked to persistent pulmonary hypertension but this couldn’t be confirmed.

The other possibility was an asphyxial event, which may have resulted from the positioning of Evana Jade on her mother’s chest, wrapped in towels and attempting to feed.

A detailed review by Counties Manukau District Health Board [DHB] noted that ministry guidelines were not followed in that mother and baby were left without medical supervision several times in the first hour.

The review also noted that the information displayed at the maternity unit for calling St John Ambulance Service advised calling the professional 0800 number rather than 111.

This led to the non-urgent phone number being used to initially call an ambulance, potentially delaying the hospital transfer by up to 26 minutes.

Also, there was a miscommunication to St John regarding

Situations such as the one in this case, are extremely difficult. Coroner Erin Woolley

the type of ambulance required, and the use of jargon such as “air puff ” and “baby bus” led to an ambulance not designed to provide medical treatment being sent initially.

The coroner noted the ambulance delay was not the fault of St John, as it responded to the initial information.

“I appreciate that situations such as the one in this case, are extremely difficult and distressing, however, it is critical that health professionals retain the ability to clearly communicate the exact nature of the emergency on hand,” the coroner said.

She commended St John for its proactive approach in investigating the cause of the delay and making changes to its operating procedures.

The Counties Manukau Health DHB report into the death listed recommendations including that midwives and lead maternity carers know about its 2015 guidelines on water immersion during labour and birth.

The DHB said in a response to the coroner that the document was updated in 2019 and was circulated to all women’s health clinicians and lead maternity carers.

The DHB now also had guidelines that described the processes and expectations around an emergency transfer from one of its primary birthing units to Middlemore. The coroner said because of the DHB action, further recommendations weren’t necessary.

The DHB told Open Justice it would offer its sincere condolences to the wha¯nau on the death of Evana-Jade.

“A comprehensive review into the circumstances leading to EvanaJade’s death was undertaken by Counties Manukau Health and this has been acknowledged by the coroner,” a spokesperson said.