Key Takeaways:
- A stillborn baby’s death at Waitākere Hospital has been linked to a series of failures, including a blocked caller mode on the hospital’s bedside telephone system.
- The Health and Disability Commissioner found that Health NZ Waitematā breached a section of the health consumers code by failing to ensure care was managed in a way that was safe and appropriate.
- The commissioner was critical of the hospital’s policy and the doctor’s workload, which resulted in compromised communication about the care plan.
- The hospital has apologized and made immediate changes following the incident, including deactivating the call-blocking function on all telephones used by women and couples to contact staff.
- The commissioner has recommended that the hospital update its policy on the threshold for calling in a second on-call obstetrician and consider amending its reduced fetal movements policy to include maternal ethnicity as a risk factor for stillbirth.
Introduction to the Incident
The Health and Disability Commissioner has released a decision regarding a complaint about the antenatal care provided to a woman at Waitākere Hospital, which resulted in the stillbirth of her baby. The commissioner, Rose Wall, extended her condolences to the couple for their loss and identified a series of failures, including a blocked caller mode on the hospital’s bedside telephone system. The blocked caller mode was one of several failures, including those of a doctor and Health New Zealand Te Whatu Ora, which were identified by the commissioner following a complaint from the baby’s father.
The Mother’s Care
The mother, who was in her late 20s, arrived at Waitākere Hospital at 40 weeks and three days’ gestation, reporting reduced fetal movements. Cardiotocography (CTG) monitoring was carried out, which recorded reduced movement two days earlier. The consultant obstetrician did not think the CTG was indicative of fetal hypoxia and recommended continued CTG monitoring. However, the monitoring was not repeated overnight, despite the mother and her partner expressing concerns about the baby’s wellbeing. The midwife’s care plan was also criticized, as she did not restart monitoring until 6:50 am, at which point no fetal heartbeat could be found, and it was confirmed that the baby had passed away.
Failures in Care
The commissioner found that Health NZ Waitematā breached a section of the health consumers code by failing to ensure care was managed in a way that was safe and appropriate. The commissioner was critical of the hospital’s policy and the doctor’s workload, which resulted in compromised communication about the care plan. The doctor’s busy workload meant that she was dealing with responsibilities beyond one senior medical officer’s capacity, and the commissioner found that this was a barrier to the provision of timely and safe services. The commissioner also found that the midwife’s account of events was more compelling than the doctor’s, and that the midwife had not been told of the mother’s concerns about the baby’s wellbeing.
Response from Health NZ Waitematā
Health NZ Waitematā has apologized for the tragic incident and has made immediate changes following the incident. The organization has deactivated the call-blocking function on all telephones used by women and couples to contact staff and has confirmed that there have been no further instances of blocked calls since the events that led to the complaint. The commissioner has also recommended that the hospital update its policy on the threshold for calling in a second on-call obstetrician and consider amending its reduced fetal movements policy to include maternal ethnicity as a risk factor for stillbirth.
Conclusion and Recommendations
The commissioner’s decision highlights the importance of ensuring that hospitals have sufficient levels of skilled and experienced staff to provide safe, timely, and competent care. The commissioner’s recommendations, including deactivating the call-blocking function and updating the hospital’s policy on calling in a second on-call obstetrician, aim to prevent similar incidents from occurring in the future. The incident also highlights the need for clear communication and collaboration between healthcare professionals to ensure that patients receive the best possible care. The commissioner’s decision is a reminder of the importance of prioritizing patient safety and wellbeing, and of the need for healthcare organizations to learn from adverse events and make changes to prevent similar incidents from occurring in the future.