DHB’s Care Of Woman And Her Baby

Deputy Health and Disability Commissioner Rose Wall today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a woman and her baby.

The woman, aged in her twenties at the time, had a difficult pregnancy. She lost weight and required multiple hospital admissions for severe morning sickness (hyperemesis), and her baby’s growth was restricted. However, her midwife did not record the woman’s weight or fundal height (a measurement taken to assess fetal growth) at every antenatal assessment. In the early months of the woman’s pregnancy the midwife continued to review the woman when the Obstetrics team at the DHB were involved. However, the midwife did not document when she formally handed over care to the Obstetrics team, and there was no documented plan later in the pregnancy when transfer was necessary.

When the woman was under the care of the DHB, there was no formal management plan and no clear guidelines for staff on the management of severe morning sickness and malnutrition. When the baby was born, she was recognised as "at-risk" owing to her low birth weight. However, the baby’s blood glucose level was not monitored in a timely manner, and a paediatric review was not requested. In addition, she was administered a higher than recommended dose of phenobarbitone (a barbiturate used to prevent seizures). Her condition deteriorated, and she was admitted to the Neonatal Intensive Care Unit, where tragically she passed away.

Deputy Commissioner Rose Wall was critical that transfer from the midwife to the Obstetrics team was not clear, and a formal management plan was not documented. In addition, the DHB policy on hyperemesis and malnutrition was inadequate, the DHB’s policy on paediatric review and blood glucose monitoring was not followed, and the dose of phenobarbitone administered to the baby was not consistent with the guidelines.

Ms Wall was also critical that opportunities were missed to provide cultural support to the woman and to seek specialist advice about a baby who was significantly small for gestational age.

"I acknowledge that this extremely rare sequence of events for [the woman] and her whānau led to a tragic outcome for them with the loss of their baby," said Ms Wall. "Although it is not possible to determine whether the outcome could have been changed, I am critical that the DHB did not ensure that staff were supported with adequate systems to guide and deliver appropriate care, including a requirement to develop comprehensive management plans in such complex cases."

Ms Wall recommended that the DHB provide an update on implementation of the nausea and vomiting in pregnancy guidelines. She also recommended the DHB consider developing guidelines for when consultation with a multidisciplinary team and development of a formal plan is required for a significantly small for gestational age baby or a woman with severe symptoms, and for when a woman with a small for gestational age fetus requires referral to a fetal medical specialist or a larger centre.

Finally, Ms Wall recommended the DHB consider the need to provide appropriate cultural support in complex cases; provide staff training on the use of the hypoglycaemia kit and the management of neonatal hypoglycaemia; review the guideline for administering phenobarbitone and ensure that all relevant staff are aware of the guideline; and provide a written apology to the woman.

Ms Wall recommended that the midwife provide an update on the Order Concerning Competence issued to her by the Midwifery Council of New Zealand.

To read the full report on case 18HDC00384, visit the HDC website.

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