Failures lead to baby death

DHB, midwife found in breach of health and disability code

Anewborn girl died after a midwife failed to record a pregnant mother’s severe morning sickness and weight loss restricting her baby’s growth.

“They say that time heals all wounds, but I can say that the wha¯nau will never get over the passing of [their baby],” a family spokesperson said.

An investigation released yesterday found Bay of Plenty District Health Board and its midwife in breach of the Code of Health and Disability Services Consumers’ Rights for multiple failures in the care of a woman and her baby.

The woman, who cannot be named for privacy reasons, was in her 20s at the time and had a difficult pregnancy.

She lost weight and required multiple hospital admissions for severe morning sickness (hyperemesis), and her baby’s growth was restricted, the Health and Disability Commission (HDC) report said.

However, her midwife did not record the woman’s drop in weight or baby’s growth at every antenatal assessment and specialist doctors who took over the care later on in the pregnancy weren’t told.

The investigation found there was no formal management plan and no clear guidelines for staff to monitor the severe morning sickness and malnutrition.

When the baby was born, she was recognised as “at-risk” due to her low birth weight.

She was also administered a higher-than-recommended dose of anti-seizure medication.

Her condition deteriorated, and she was admitted to the Neonatal Intensive Care Unit, where she died.

Deputy Commissioner Rose Wall said it was impossible to know whether the baby could have been saved. However she criticised the DHB’s lack of adequate systems in place to support staff, including a requirement to develop comprehensive management plans in such complex cases.

“This extremely rare sequence of events for [the woman] and her wha¯nau led to a tragic outcome for them with the loss of their baby,” Wall said.

A family spokesperson said in the report that the wha¯nau would like assurance that this will not be the case for any future pregnant mothers who find themselves in that position.

The deputy commissioner recommended the DHB update a number of its policies and consider the need to provide appropriate cultural support in complex cases.

They were also ordered to provide a written apology to the woman.

The midwife was also told to provide an update on the Order Concerning Competence issued to her by the Midwifery Council.