Baby dies: Government-funded survey reveals ‘missed opportunities’ in pregnancy care

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Grieving mom “completely exhausted emotionally and physically” after losing her baby and her confidence in the public health care system. Photo / 123rf

A government-funded investigation revealed “missed opportunities” for senior doctors to intervene in the run-up to the death of a one-month-old Waikato baby.

Today, the Waikato District Board of Health was found guilty of violating the Consumer Rights Code of Health Services and Disability for caring for a pregnant woman in her 30s after losing her baby.

At 28 weeks pregnant, the woman – who cannot be named for confidentiality reasons – was rushed to Waikato Hospital with severe abdominal pain.

“The pain in my abdomen was excruciating and all I could do was sob,” the woman said in the HDC report.

She was evaluated by the obstetrics and general surgery teams, but they could not find the cause of the pain.

In the report, the woman said a doctor quickly examined her abdomen by pressing on it, causing severe pain that she could barely breathe between sobs, then left the room.

“He didn’t tell me what he was thinking, what the plan was, what he thought was wrong with me… I was then left in agony for another two hours without any other vital sign is finished despite [RM F] monitoring me regularly. “

The doctor said in the report that the clinical picture at the time was not clear and the blood results did not demonstrate the likelihood of an intra-abdominal inflammatory cause.

The woman collapsed 17 hours later and was found to have a ruptured uterus.

Her baby initially survived, but died a month later from hypoxia at birth – a condition in which the baby’s brain and other organs do not receive enough oxygen and nutrients before, during or immediately after birth.

“This whole experience has left me completely emotionally and physically exhausted and suspicious of the medical profession,” the grieving mother said.

The report pointed out that a ruptured uterus without a scar in a woman who was not in labor was extremely rare – occurring in nearly 1 in 100,000 births – and difficult to detect.

A doctor said in the report that he had only seen one other case in his 34 years of medical practice.

Deputy Health and Disability Commissioner Rose Wall accepted the scarcity of the woman’s condition and acknowledged that “aspects of the woman’s care were well managed”, but criticized the DHB for “missed opportunities for heightened oversight by senior officials” and “inadequate documentation” of some reviews.

“[There was] a lack of effective communication and coordination between the obstetrics and general surgery teams contributed to a delay in the appropriate radiological assessment, ”Wall said.

In the report, the deputy commissioner said the DHB should also apologize to the woman and her family.

The clinical director of obstetrics – who has not been appointed – said in the report: “I would like to send my sincere condolences to [Mrs C] and his partner for the loss of [Baby C] and for the traumatic events they experienced during their stay at[thepublichospital”[thepublichospital”[l’hôpitalpublic”[thepublichospital”

Wall advised DHB to provide evidence of recent staff training on care coordination, escalation of care, and documentation.

Wall also suggested using this case as a basis for staff training and reporting on its implementation of the New Zealand National Maternity Early Warning System (Mews).


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