Multiple Complaints And Multiple Breaches Of Code By Midwife 21HDC01864

The Deputy Health and Disability Commissioner has found a midwife breached the Code of Health and Disability Services Consumers’ Rights (the Code) on multiple occasions in her care of seven mothers and a baby.

The midwife concerned was a self-employed lead maternity carer who had an access agreement with Health New Zealand|Te Whatu Ora to use its maternity facilities and birthing units.

The complaints were sparked by Health NZ which wrote twice to the Midwifery Council about the care the midwife had provided to the women and baby.

The first letter followed a stillbirth and at that time Health NZ suspended its access agreement with the midwife. It noted it had ongoing concerns about the midwife’s competence. It wrote a second time to the Midwifery Council providing a timeline in relation to events involving six other consumers between 2017 and 2021.

In her report released today, Rose Wall said, "The circumstances of this investigation are a salient reminder of the importance of professionals ‘speaking up’ when they observe an emerging pattern of poor care or issues of clinical concern."

Sadly, two women delivered stillborn babies under the midwife’s care. One of those women went on to develop multiple organ failure which required time in the intensive care unit. She was subsequently diagnosed with acute kidney failure, postpartum haemorrhage, and HELLP syndrome (a severe type of pre-eclampsia).

In her decision, Rose Wall noted there were emerging themes regarding the midwife’s practice, which included documentation not meeting accepted midwifery standards, lack of documentation of consultation with, and handover to, secondary care, sparse documentation of assessments and of phone discussions, lack of patient history review and lack of baseline observations to determine fetal and maternal wellbeing during critical stages of labour.

"The numerous failures by [the midwife] represent a pattern of poor care and, overall, the care provided by [the midwife] was not in keeping with the standard reasonably expected of a midwife," said Ms Wall.

She found the midwife breached Right 6(1) for failing to provide one of the women with information she was entitled to receive under the Ministry of Health’s Guidelines for Consultation with Obstetric and Related Medical Services.

Ms Wall also found that the midwife breached Right 4(1) in her care of three women, for failing to:

- Recognise a condition that required consultation with another medical practitioner

- Perform palpation and maternal baseline observations

- Monitor maternal and fetal wellbeing and perform ongoing observations at critical stages of labour

- Respond with timely and appropriate interventions when there were indications of difficulty.

Finally, Ms Wall found that the midwife breached Right 4(2) in her care of five women for the standard of her documentation.

The midwife is no longer practising. Ms Wall has recommended that she formally apologise to the complainants via HDC and, should she return to practice, undertake the required training recommended by the Midwifery Council.

Note:

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

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