A communication and coordination mix-up between ambulance providers and a midwife has been determined to have been a major factor in a baby suffering a brain injury according to Deputy Health and Disability Commissioner Rose Wall.
A report into the 2019 incident was released today, stating a woman had an unplanned home birth. She gave birth to her son with her registered midwife present.
When the midwife noticed that the baby was in respiratory distress, she called an ambulance and conveyed that a newborn baby with signs of respiratory distress needed to be transported to hospital.
The ambulance arrived with a paramedic and an emergency medicine technician. However, the ambulance did not have an appropriate neonatal-sized oxygen probe for monitoring the baby’s oxygen levels, or an appropriate setup for the safe transfer of a baby. Instead the baby was transferred to hospital in a car seat.
The baby was not monitored during the ambulance journey. The midwife was seated and belted approximately one metre away and was unable to lift the baby’s chin to increase his airflow. Both ambulance officers sat in the front of the ambulance, and did not assess the baby.
When the baby arrived at the local hospital he was hypothermic and grunting, with increased work in breathing. Subsequently, he was diagnosed with a brain injury due to the lack of oxygen flow to his brain.
The ambulance provider told the Health and Disability Commission (HDC) that previously it had formally agreed with the New Zealand College of Midwives that if a midwife is present, the midwife is in charge of the situation (care provision and decision-making) unless the midwife formally hands over to the ambulance staff.
However, the Midwifery Council of New Zealand told HDC that "as the Responsible Authority", it was not aware of any such agreement. The ambulance provider maintained that the midwife remained in charge in the case.
During the investigation, issues were also raised about the size of the baby and the lack of GROW charts (software used for customised assessment of growth and birth weight) used during the pregnancy.
Deputy Commissioner Rose Wall identified three key issues: "The lack of national consensus regarding the use of GROW charts, the absence of specific neonatal equipment in New Zealand front-line ambulances, and the lack of guidance and clarity on lines of responsibility between midwives and ambulance providers during the transfer of neonates to hospital."
"I’m satisfied that the individual providers in this case were not solely responsible for the poor care of [the baby], and that wider systemic change is needed in order to prevent similar occurrences," Wall said.
Noting the specific issues raised by this case, she recommended that these groups initiate conversations and work together to address the issues and improve patient safety. She also made five suggestions for improvement to be used as a starting point to initiate conversations and promote further collaboration between the relevant groups.
"I hope that these suggestions will go some way towards strengthening the cooperation and coordination between midwifery and ambulance services within New Zealand," Wall said.
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