The woman's lead maternity carer (LMC) for the second pregnancy was a hospital midwife, who referred the woman to an obstetrician because of her previous caesarean section.
One day after her due date the mother told her LMC her baby's movements had decreased.
The following day the woman repeated her concerns about decreased fetal movement to the obstetrician. The obstetrician conducted a bedside ultrasound scan and other monitoring, which they concluded were reassuring.
At that time, the woman was recovering from a chest infection and taking antibiotics, so the obstetrician decided to delay an elective caesarean until the woman's symptoms cleared.
She was booked to have her caesarean when she would have been nine days overdue, but the day before the operation, it was discovered that her baby had died.
The woman delivered her stillborn baby by induction the next day.
Her LMC intended to be present for the delivery, but poor communication between her and the midwives at the hospital contributed to her not being present to support the woman at the delivery.
The woman and her partner told Mr Hill they were "dismayed" the caesarean section was delayed despite all the "warning signs" present at the time of the due date, including the decreased fetal movement.
Mr Hill was critical of the obstetrician for not taking a more cautious approach to the management of the woman's second pregnancy because of her various risk factors.
In particular the obstetrician should have considered whether a series of ultrasound growth assessments were warranted.
The doctor should have arranged for the caesarean to be performed before she was six days overdue, Mr Hill said.
"To delay the caesarean section until the woman was nine days overdue, without any assessment in the interim, was suboptimal."
He recommended the doctor apologise to the mother.
Mr Hill was also critical of hospital staff, who he considered should have recognised that the delivery would be distressing for the woman, and should have worked to ensure that she had appropriate support present, including her LMC.
He recommended the hospital improve its policy on caring for women with high-risk pregnancies and improve communication with midwifery staff.
Mr Hill expressed concern that the LMC had not appreciated the nature and extent of her clinical responsibilities during the latter part of the woman's pregnancy.
He recommend she reflect on her role and responsibilities as a LMC, in particular her clinical responsibilities to the woman after a specialist referral had been made.
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