Mr Hill's report, which names none of the parties, found fault with the registrar and a hospital midwife. The midwife also apologised to the family and has ceased practising midwifery. Mr Hill did not refer either for consideration of disciplinary proceedings.
The baby, large for her gestational age, had become increasingly distressed during labour and suffered a progressive lack of oxygen. An early sign was that when the fluid from around the fetus was released, it was stained with meconium (fetal faeces).
Because of this, the cardiotocograph (CTG) monitoring of the fetal heart rate and the mother's contractions should, by the DHB's own policy, have been continuous, but for some time it wasn't. The ultrasound strap kept slipping off the mother's abdomen. An ACC report on the case noted the failure to attach a CTG electrode to the scalp of the fetus.
The girl's shoulders got stuck for some time during the vaginal delivery and, once born, she had to be resuscitated. Twenty-four minutes passed before she took her first breath. She was flown to a neonatal intensive care unit in a main centre but died soon after.
The midwife had repeatedly raised concerns during the labour, but the registrar remained unconcerned.
Mr Hill said the midwife should have contacted the on-call obstetric specialist. The CTG was abnormal and should have prompted actions including arranging an urgent caesarean.
The series
Five years of hospital death rates have been made public for the first time - in the Herald. We compare health boards, investigate where lives are being lost and the battle to save them.
This week
Monday - District health boards compared, is death rate linked to healthcare quality, and how a simple checklist helps surgeons to avoid mistakes.
Yesterday - Waitemata DHB boosts heart-care capacity. A bereaved father questions medical justice.
Today - Waikato DHB strives to understand its high death rate, medication safety, and a doctor's apology.
Tomorrow - Palliative care helps Auckland DHB's good performance. A widow fights for changes.
Friday - Obesity skews the statistics in South Auckland. Lives saved by reduction of blood infections.
Contact us
Tell us your experience of hospital care. Email Martin Johnston by clicking the link below.
