'Fresh eyes' investigation finds systemic failings in case of stillborn baby

RNZ News

05-05-2025

The Commissioner ordered the Auckland District Health Board to apologise to the parents.
Photo:
123rf.com
After initially refusing to investigate, the Health and Disability Commissioner has found systemic failings in the care given to a woman whose daughter was stillborn.
The woman, who suffered three bleeds during what was deemed a "high risk" pregnancy in 2013, made a complaint to the HDC after the death of her child.
The HDC decided to take no further action, but after a review by the Ombudsman, reopened the complaint in 2021 and took a "fresh eyes" approach to the investigation.
The baby's family said it had continued to strive for change, rather than place blame, and would do everything in its power to prevent this tragedy from falling upon another family.
In her findings, Commissioner Morag McDowell said the inquiry highlighted the importance of monitoring an unborn baby's movements.
She found the lack of an ultrasound at Auckland Hospital after the woman's admission for a third bleed was not a failure in care, but several failings by Auckland District Health Board (ADHB) amounted to a breach of the Code of Health and Disability Services Consumers' Rights - including the woman's early discharge, a failure to communicate with the midwife and not arranging follow-up care within an appropriate timeframe.
The lead maternity carer - a community-based midwife - was found to have given the woman incorrect information about what to consider normal movement from the baby and the Commissioner was also critical of the midwife's documentation.
Noting the changes already made at ADHB, such as providing patients with information about foetal movement monitoring and implementing a discharge checklist, McDowell recommended it apologise to the family and assess its treatment guidelines on antepartum haemorrhages.
She recommended the midwife provide evidence of training on monitoring foetal movement.
The woman - known as Mrs A - was healthy, in her 30s and the pregnancy was her second. It was classified high risk, after she developed preeclampsia in her first pregnancy and underwent a caesarean section at 37 weeks.
At 16 weeks pregnant, she had a bleed and an ultrasound found a haematoma on the wall of her uterus.
A few weeks later, following a second bleed, a scan did not find a haematoma and the cause of the bleed was not identified.
At 30 weeks, Mrs A suffered a "significant" bleed - according to independent expert Dr Michel Sangalli - and was transferred from a secondary hospital to Auckland Hospital, a tertiary institution.
She was observed there for two days, while her bleeding stabilised, but no source was identified and monitoring showed the baby's heartbeat was normal.
The plan was for her to remain in hospital for another 24 hours and undergo a second urinary protein-to-creatinine ratio test - an indicator for preeclampsia, but she was discharged after a few hours, without being tested.
Ten days later, Mrs A and her husband had an appointment with her midwife. Two days after that, at 32 weeks, Mrs A went into early labour and monitoring showed the baby had no heartbeat.
She was induced and gave birth to a stillborn daughter. A post-mortem found no evidence of a recent bleed in the placenta, but the placenta showed signs of tissue death.
The Commissioner investigated Mrs A's care in the context of her suffering the three pregnancy bleeds before her daughter was stillborn.
With regard to ADHB, the inquiry considered whether an ultrasound should have been performed at Auckland Hospital after Mrs A's third bleed to assess the baby's wellbeing, and the information and communication provided on discharge.
McDowell also looked at the information provided by the midwife on fetal movements during pregnancy and the care to Mrs A immediately after she was discharged from hospital.
In his advice to the Commissioner, Dr Sangalli said the single most important mishap in the case was the lack of an ultrasound after Mrs A's third bleed at 30 weeks pregnant and he believed this to be a breach of the profession's standards.
However, McDowell said there was no consensus on whether an ultrasound should have been given, noting two clinicians - including Dr Sangalli - said a scan was warranted, whereas eight clinicians (six from ADHB) did not.
Noting that Dr Sangalli said the lack of an ultrasound was only a mild breach, the Commissioner found that the failure to undertake an ultrasound at Auckland Hospital did not amount to a breach in the standard of care.
McDowell did find Mrs A's care at the hospital fell below the accepted standard and the several failures amounted to a breach in the code by ADHB.
In particular, she noted Mrs A was discharged without a clear reason, despite the plan to remain in hospital for a further 24 hours and undertake a test that could indicate preeclampsia.
McDowell said follow-up appointments were scheduled too late - outside the appropriate timeframes - her discharge information was not given to her midwife or local hospital, and she was told she could leave without being given advice about monitoring her baby's movements.
Mrs A and her husband said they raised their concerns about their baby's "significantly" reduced movements in an appointment with the midwife 10 days after leaving hospital.
The midwife said, while foetal movement was discussed, she said Mrs A stated she was "unsure" about the baby's movements, not concerned.
The Commissioner was unable to make a finding about what was discussed at the appointment.
However, she said the midwife's advice about expecting "at least 10" movements from the baby per day was incorrect and she was critical of the midwife's documentation, but the failures did not amount to a breach.
She found the care immediately provided by the midwife after Mrs A's discharge from hospital was acceptable.
ADHB and the midwife accepted the Commissioner's provisional findings.
In addition to changes already made by ADHB - including providing patients with information about foetal movement monitoring, sharing discharge notes with lead maternity carers and other DHBs, and a discharge checklist - McDowell recommended the DHB review its guidelines on investigating antepartum haemorrhages to see whether further clarity was needed and writing a letter of apology to the family.
The midwife said she now asked for discharge papers from Auckland Hospital and advised clients to call her, if they had trouble getting an ultrasound. In addition to this, the Commissioner recommended the midwife provide evidence of training she'd undertaken about foetal movement and how she provides that advice to patients.
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