Baby stillborn after mother’s concerns not properly acted on

Source: Radio New Zealand

A woman’s baby was stillborn after multiple errors were made and risk factors overlooked in a stretched Auckland health system.

The Health and Disability Commission said the baby’s parents were failed by Health NZ Waitematā, which runs Waitākere and North Shore hospitals.

The woman had repeatedly raised worries with health staff before she lost her baby at 38 weeks pregnant in 2021.

Deputy commissioner Rose Wall’s report outlined how, at various times in her pregnancy, risks were not properly acted on.

They included the woman’s large uterine fibroid, the baby’s small size, a small amount of amniotic fluid, and abnormal heartbeat at hospital.

The situation escalated when she went to hospital at about 38 weeks pregnant, worried about a lack of movement.

After monitoring, she was sent home but returned the next day. Her baby had died.

The woman told the commission the lack of attention, repeated mistakes and poor communication caused “irreparable harm”.

“These human errors ultimately led to the death of my baby,” the woman told the commission.

“I did everything I could to raise concerns and advocate for my wellbeing and that of my baby, but I was not heard … This has not only been a clinical failure but a deeply personal tragedy that has left lasting emotional and psychological damage.”

The mistakes began early, shortly after the woman was found to have a large fibroid – a benign uterine growth that is often harmless but usually needs extra monitoring.

Her midwife referred her to an obstetrician – but not enough plans were made to monitor the baby’s growth in the weeks to come.

If that had happened, the baby’s small size may well have been identified early, Wall said in her report.

The woman told the commission she had repeatedly asked for an ultrasound from 28 weeks gestation but her midwife did not refer her until 37 weeks when the midwife became concerned about the baby’s growth.

It took 10 days to get an emergency ultrasound.

That scan showed the baby was small and had a low amount of amniotic fluid but the radiologist’s report contradicted itself, saying in one place that the fluid was normal and in others that it was low.

The next day, the woman told the midwife she had not felt her baby move since the scan.

What happened at hospital

The woman’s midwife rang the hospital to tell them the woman was on her way, having warned her she may need to be induced or have a caeserean.

She went to Waitākere Hospital where the baby’s heart was monitored.

It was found to be normal in general but there had been one instance of it dropping suddenly and recovering slowly.

After more monitoring, the heartbeat returned to normal and the woman was sent home. She was told to come back two days later for further monitoring unless she was concerned before that.

But the next day she returned because she could not feel her baby move.

The registrar did an ultrasound and could not find a heartbeat.

“Sadly, Baby A had died,” the report said.

Fault with Health NZ

Deputy commissioner Rose Wall said care provided to the mother by Health NZ Waitematā was inadequate.

“No action was taken in light of the large fibroid; information that was provided by the [woman’s midwife] was not passed on; there was a failure to recognise that a normal-sized baby was unlikely to have low amniotic fluid volume; and it was not recognised that Baby A was a small for gestational age baby because the estimated fetal weight was plotted … incorrectly,” she said.

“These errors were made by multiple staff, for which I hold Health NZ Waitematā responsible.”

An expert who reviewed the case found the woman’s midwife had repeatedly tried to communicate to hospital staff about the baby’s risk factors – including when the hospital sent her home.

There were multiple chances to identify that the baby was small, the expert said.

“He said that if it was known that Baby A was small, then the clinical management of the acute presentation would have been different, as an small for gestational age baby with reduced fetal movements, low amniotic fluid volume, and an abnormal [heart scan] would have led to admission, if not delivery,” the report said.

Wall also criticised the radiologist for including contradicting information about the amniotic fluid in her report.

A stretched hospital

The woman would ordinarily have been sent to North Shore Hospital but it was too full when her midwife called so she was sent to the smaller maternity unit at Waitākere.

The senior obstetrician at Waitākere that day told the commission they were not consulted or informed about the diversion order.

“They became aware of it only when patients started to arrive from North Shore Hospital,” the report said.

There was normally only one senior obstetrician on duty there, but she requested back up and Health NZ had sent a junior doctor to help.

Health NZ responds

Health NZ said it fully accepted the findings and recommendations in the report.

Its director of operations at Waitematā, Brad Healey, said it aimed to provide excellent healthcare and was deeply sorry it did not in this case.

“We have apologised to our patient for the failings identified in the report, the ongoing distress and acknowledged that this apology is likely to be of limited comfort after such a tragic loss,” he said.

Health NZ Waitematā had made process changes including to ensure abnormal findings or urgent issues are escalated as soon as possible, he said.

The commission’s report said the organisation also had contingency plans in place if maternity patients had to be diverted to other hospitals.

The mother told the commission she wanted to see change.

“I hope that this reaches the outcome it deserves so that no other mother or family has to experience the same preventable heartbreak,” she said.

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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand