A midwife and a district health board have been found in breach of the Code of Health and Disability Services Consumers' Rights after a woman gave birth to a stillborn baby due to poor communication.
It comes after the midwife, a lead maternity carer, failed to advise the woman - who was at risk of complications due to her high body mass index and an inconclusive Hepatitis C status - to consult with an obstetrician about her care, a report released today by Health and Disability Commissioner Anthony Hill has found.
The woman was later admitted to the hospital in early labour, which was "augmented with syntocinon without a full obstetric review" after the senior medical officer and the obstetric registrar were not advised of the risk factors, Mr Hill said in a statement.
When complications arose in the birthing process, the registrar planned for a category 2 caesarean section - a "response to fetal compromise that is not immediately life-threatening" - which was relayed to the senior medical officer through the phone as he was located elsewhere in the hospital.
The baby was stillborn.
Mr Hill found that the midwife had failed to advise the woman of the recommendations in the referral guidelines due to her weight and medical status.
He also found that the DHB was "seriously compromised" after failing to ensure that the registrar was appropriately supervised.
"The DHB's handover practice was suboptimal; there were deficiencies in internal communication; and the DHB policy relating to syntocinon was inappropriate," Mr Hill said.
The commissioner recommended the DHB "review its handover process, implement daily consultant-led ward rounds, and confirm the implementation of the associate clinical midwifery manager role, cardiotocograph interpretation cards, and weekly CTG meetings."
He also recommended that the midwife undertake training on informed consent and the referral guidelines, and for the registrar to undertake training on fetal surveillance.