A report into the care of a woman who gave birth to an underweight baby which later died has found the Bay of Plenty District Health Board failed in its duty of care and breached the Code of Health and Disability Services Consumers' Rights.
Photo: RNZ / Dan Cook
The woman, in her 20s, was admitted to hospital multiple times during her 2017 pregnancy with severe morning sickness, malnutrition and gallstones.
Her baby was born weighing only 2.5 kilograms and while it initially did well, blood results showed profound hypoglycaemia.
Health and Disability deputy commissioner Rose Wall said the management of the woman during her pregnancy by her midwife and the DHB's policies after the birth were inadequate.
"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."
The baby was also administered a higher than recommended dose of phenobarbitone which was used to prevent seizures. Her condition deteriorated, and she was admitted to the Neonatal Intensive Care Unit, where she died at five days old.
Wall also said opportunities were missed to provide cultural support to the woman and to seek specialist advice about a baby who was significantly small.
"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.
"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."
The DHB acknowledged its care was not ideal, but said that each time the woman presented to hospital her condition was taken seriously.
It said the mother may not have taken seriously enough the importance of diet advice she had been given and said she would not stay in hospital for long, discharging herself against medical advice.
In a statement from the woman's family they strongly rejected that she did not take on the advice and said eating well was near impossible given her severe morning sickness.
"Her mental health through this period should have been taken into consideration in particular the effects of being so unwell for such a long period of time."
Wall recommended 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, 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 were aware of the guideline; and provide a written apology to the woman.
Wall recommended that the midwife provide an update on the Order Concerning Competence issued to her by the Midwifery Council of New Zealand.
The woman's aunt made the complaint to the HDC.
