Report from Inquiry Into National Women's Neonates

Embargoed till 1.30pm July 6, 1999

6 July 1999

Report Of Inquiry Into Treatment Of Neonates At National Women's Hospital Made Public.

AN inquiry commissioned by Director-General of Health Dr Karen Poutasi into the provision of chest physiotherapy to preterm babies at National Women's Hospital has found a link between the treatment and deaths and brain damage in some babies.

It also raises the possibility that the treatment may have harmed other babies before the timeframe considered by the inquiry.

The inquiry was carried out by Helen Cull, QC, Dr Philip Weston (Neonatologist) and Jan Adams (Director of Nursing), and covered the period April 1993-December 1994.

"The evidence demonstrates that the chest physiotherapy applied at National Women's Hospital was more vigorous, carried out for longer and with more variability than in comparable hospitals in New Zealand, Australia and the United Kingdom," Dr Poutasi said.

Basically it finds that all preterm babies are vulnerable to brain damage for several reasons including low blood pressure. About 20 per cent get serious brain damage. For these babies the movement of their heads associated with the chest physiotherapy, in addition to the fact their brains were softer than those of fullterm babies and more prone to damage, combined to produce a very specific brain injury - able to be seen on ultrasound scans.

The chest physiotherapy was initiated at National Women's from 1985. It was not applied in the same way in any other neonatal unit in New Zealand.

Dr Poutasi said since receipt of the report she had asked Auckland Healthcare to conduct a Lookback programme to identify any other babies who may have been brain-damaged as a result of chest physiotherapy from 1985-April 1993.

"Meanwhile let me reassure any parents who think this may affect their child that the type of brain damage associated with the treatment is extremely unusual. The Lookback programme is likely to identify very few, if any, children who suffered in consequence of this approach to treating premature babies."

Auckland Healthcare and Ministry officials were discussing the best way of conducting the Lookback programme, and details would be announced as soon as they were finalised.

"While it is always good to know the answers, it does not in any way lessen the tragedy for those involved," Dr Poutasi said, "nor does it detract from our compassion for them. Our thoughts are with the families.

"We are also mindful of those health professionals who initiated the treatment motivated solely by the desire to do their best for pre-term babies and enhance their chances. To know that in some cases the outcome was tragically different from what they hoped for must be devastating."

Dr Poutasi said the inquiry team had drawn eight lessons from the inquiry, covering professional issues such as peer review, informed consent, record keeping, the difference between research and internal audit, the referral of consumers to advocacy services and ongoing audit and research.

The lessons and the Ministry of Health response to each are detailed in the attachment to this statement.

The Ministry is also referring the report to the Medical Council, the Nursing Council and the Physiotherapy Board for their consideration, and any action they see fit.

It is also discussing the outcome with ACC, which initially referred the matter to the Director-General.

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