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DHB offered 'seriously sub-optimal' care to pregnant woman whose baby was born with brain damage, report finds

November 18, 2019

A DHB offered "seriously suboptimal" care to a pregnant woman whose baby was subsequently born with brain damage according to Health and Disability Commissioner (HDC) Anthony Hill.

A report from the HDC outlines the care provided to a woman who experienced premature rupture of membranes (her waters broke) when she was 29 weeks pregnant.

"The woman was admitted to hospital so the wellbeing of her baby could be monitored.

"Six days after her admission there were signs the woman’s condition was changing and she reported reduced fetal movements," the report states.

The report then went on to outline the events which directly affected the baby's health.

"A midwife, who was a new graduate, carried out routine CTG monitoring of the baby’s heart rate that evening, but was unable to obtain a clear tracing.

"She consulted a second midwife, who has a different account of what information and advice was exchanged. No action was taken for the next hour until another midwife came on duty, assessed the CTG and called the obstetric team.

"A scan showed the baby was severely compromised and the woman had an emergency caesarean. The baby was resuscitated but suffered significant brain damage."

In his findings, Mr Hill said that the care provided by the DHB was seriously suboptimal and that it did not have in place adequate systems to ensure that staff were supervised and supported in their decision-making.

He also found its culture did not support staff to report concerns and ask for assistance.

He noted that since these events the DHB has made a significant number of changes to its women’s health service, which showed a strong commitment to improve the quality of its service.

Mr Hill also recommended that apologies be provided to the baby’s parents, and that the Midwifery Council of New Zealand undertake a competency review of the first midwife’s practice, and of the second midwife’s practice should she re-apply for a practising certificate.

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