Fatal error
.
A newborn girl died after a lab test result revealing a deadly but treatable infection went missing at Wellington Hospital.
The mother complained about the midwife and being pressured to leave hospital early, but the health and disability commissioner ruled that it was the missing lab test that led to the baby’s death. Her first-time mother was discharged about five hours after the birth.
The girl died at home in November 2007, less than 20 hours after her birth at Wellington Hospital.
That policy did not apply to first-time mothers, and was not in effect at the time of the birth, but was a symptom of the pressure the maternity ward was under at the time.
The birth happened as Capital and Coast District Health Board was issuing a memo encouraging midwives to discharge mothers within six hours of giving birth.
The mother said this week: “I can’t say my baby would definitely be OK [if she had stayed] but under professional care I believe she would have had a better chance.
The couple later complained to the commissioner about the standard of care provided by the independent midwife, saying they had felt pushed to leave hospital early. How could I know what is the normal temperature?”
In a decision the previous month, commissioner Ron Paterson said it seemed a “striking coincidence” that the case happened as Capital and Coast issued its early discharge memo. At home I always felt she was cold, but it was my first baby.”
The report is not public but The obtained a copy. “I have no doubt that you felt pressured to leave the hospital. “I find it very difficult to put this statement into the baby’s box,” the mother said.
The parents are angry with the commissioner’s decision, which they do not think is impartial.”
The commissioner found the midwife provided “appropriate care”, although he identified communication and information problems. “I feel it’s an insult to her, it’s not based on much truth, it’s not really listening to me.
“This systems error, rather than the actions of [the midwife], is the true cause of [the baby's] death.
He said the death was caused by the failure to provide antibiotics to treat the infection evident in a swab result that had gone missing. Penicillin was recommended during childbirth.”
The missing test, which the midwife had ordered two days earlier, showed the mother had group B streptococcus bacteria. She did a second swab but those results were not available until after the baby’s death. But when the midwife asked for the test result on the day of birth, it could not be found. “What’s the point of having a second swab on the day of the baby’s birth?”
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An autopsy found the cause of death was pneumonia and persistent pulmonary hypertension (when a baby’s body does not adapt to breathing outside the womb). .
In a letter to Capital and Coast, Mr Paterson said he was satisfied the DHB had made “necessary improvements”.
In a letter to Capital and Coast, Mr Paterson said he was satisfied the DHB had made “necessary improvements”. But he has made extra recommendations and asked it to report by the end of this month.
Capital and Coast women’s health clinical director John Tait said the DHB had taken “significant steps” to address the issues raised by the “tragic event”. It invited the family to meet “to express our sincere apologies and discuss the improvements made in our systems”.