The baby died 22 hours after the birth and a Coroner's inquest is yet to rule on causes. Photo / supplied, file
The baby died 22 hours after the birth and a Coroner's inquest is yet to rule on causes. Photo / supplied, file
A family grieving over the death of their baby girl in hospital in 2016 suffered further distress when an unwitting Southern District Health Board anaesthetic service rang to ask for feedback on its care, the Health and Disability Commissioner says.
The death of the baby after just 22 hours awaits a Coroner's inquest, but the SDHB was further criticised by deputy commissioner Rose Wall for not immediately notifying the Coroner of the case.
Systemic issues within the SDHB and substandard care by several clinicians led to multiple omissions in the care of the baby's mother and the infant herself, Wall said in a recently released report.
Confusion reigned from early in the birth, as midwives and doctors all mistook the vaginal wall for the baby's head.
Other problems included difficulties attaching traces to monitor the baby's condition, uncertainty as to who was in charge, and poor documentation of events.
Neonatal paediatrician Phil Weston said the baby's survival was unlikely even before errors were made in the care. Photo / Christine Cornege, file.
The next day, a doctor incorrectly administered a dose of the sedative midazolam five times higher than he intended, to a baby already in very poor health.
The commissioner's expert witness, Waikato neonatal paediatrician Phil Weston, said the doctor's error was "understandable in context but an error nonetheless".
"I feel confident that it had nothing to do with death, which was inevitable in my view from a much earlier stage," Weston said.
Wall said the SDHB carried out a serious adverse event review, and its findings resulted in the Coroner being notified.
She agreed with Weston it was disappointing that the Coroner was not told immediately, given the baby's death was unexpected.
Blunders continued after the baby's death as the SDHB's anaesthetic service was unaware of what had happened.
"This led to a distressing follow-up telephone call," Wall said.
The SDHB told Wall that, among a raft of changes brought in following the death of the baby, it had updated its neonatal death documentation checklist to include notifying all services involved in the care of a mother and baby.
All deaths in the neonatal intensive care unit were now also referred to the Coroner.
"I would like to pass on our sincere condolences on the death and loss of [Baby B] and apologise unreservedly for the inadequate care which both [the mother] and [the baby] received," SDHB chief executive Chris Fleming told Wall.
"I would also like to thank the family and the HDC for raising concerns about the care of [mother and baby] with us, as this helps us to reflect on the care provided, and also on how we can improve the service we deliver in the future to our mothers and children."
Wall said multiple DHB clinicians cared for the baby, but their work was "suboptimal in a number of respects".
Overall, their failings were the responsibility of the SDHB, although it was not possible or appropriate for her to say if any led to the baby's death.
"In my opinion, multiple aspects of the care provided to [the mother] by SDHB fell short of acceptable standards," Wall said.
"Notwithstanding the personal responsibilities of the individual providers in her care, communication issues, which I consider were SDHB's responsibility, led to confusion about who was taking responsibility for [the mother's] care."
The doctor who gave the incorrect injection had apologised to the family.
He acknowledged the error, which he said happened in "a highly pressured and emergency situation, which required urgent/immediate action".
The mother's lead maternity care midwife was ordered to apologise to the family and the Midwifery Council asked to consider whether a further review of her competency was needed.
