Communication And Risk Assessment Lacking In Maternity Services Provided By District Health Board

Deputy Commissioner, Rose Wall, has made multiple recommendations to a District Health Board (DHB) to improve its maternity services following a delayed Caesarean section.

The case highlights the importance of all team members having situational awareness of an evolving picture of a baby in distress, and knowing when to halt the labour and call in further assistance.

Ms Wall found the DHB in breach of the Code of Health and Disability Services Consumers’ Rights for not providing the woman services with reasonable care and skill.

The DHB conducted a formal review into the care provided, which determined there were several points at which the care should have been escalated to the obstetric consultant and the birth expedited.

Ms Wall noted in her report there should have been an agreed strategy for managing the problems that developed as this woman’s labour progressed.

She also stated there were "missed opportunities to review the appropriateness of continuing the woman’s labour, and the poor outcomes for the woman and her baby were not the result of failings by any individuals, but rather the combination of factors within the DHB’s system that resulted in the Caesarean section being delayed."

Ms Wall further noted the importance of discussion between a midwife and their client about delivery options available and assessment of risks as part of development of a birth plan over the course of the pregnancy to ensure they are well informed and in a position to make an informed choice.

"The potential for secondary intervention and a possible Caesarean section should be discussed well ahead of the birthing event," says Ms Wall.

Ms Wall recommended the DHB provide a written apology to the woman and provide feedback on the results of its audit of partogram [1] use and details of steps taken to remedy any shortfalls found in the audit. She also recommended the DHB update its policy on fetal surveillance, and use this case as an anonymised case study for staff training. This case will also be used for educational purposes to highlight the importance of careful planning and management of labour that is failing to progress.

Ms Wall noted the issues raised in this report are indicative of the impact of delayed access to theatres and a lack of senior clinician oversight after-hours can have on patient safety. These issues are seen across complaints about regional obstetric units, and raise concerns about variation in care and geographical inequities in access to, and quality of, maternity services.

HDC has sent a copy of this report to the Ministry of Health and interim Health New Zealand to highlight these concerns. HDC has also sent a copy of the report to the Midwifery Council and the Neonatal Encephalopathy Taskforce at the Health Quality and Safety Commission, along with other professional colleges, for educational purposes.

[1] a tool used to monitor labour and prevent prolonged and obstructed labour focusing on observations related to maternal, fetal condition and labour progress

Notes

The full report of this case can be viewed on HDC’s website . Names have been removed from the report to protect privacy of the individual involved in this case.

We anticipate that the Commissioner will name DHBs and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. HDC’s naming policy can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

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