“In my view, the key issues in this case were the delay in diagnosing failure to progress in labour and the delay in recommending delivery by Caesarean section,” Wall said.
“Given that this woman’s pregnancy was high risk due to her advanced maternal age, IVF pregnancy and medical history, it would have been reasonable to take a more cautious approach and evaluate her earlier.”
In his ruling, Justice Wall said the woman was admitted to Christchurch Women’s Hospital’s labour unit in 2018 to have labour induced and went into labour three days after admission.
On the fourth day, after hours of trying to give birth naturally, the decision was made at 11pm to deliver the baby via Caesarean section.
But the doctors had to wait until the operating theatre was cleared and cleaned.
The woman’s treatment was then further delayed as another patient in urgent need of treatment was given priority.
Two hours later, labour began, but there were problems delivering the baby, who was described as “pale and floppy” when delivered. The baby was quickly taken to the nursery and required CPR.
Sadly, the newborn was diagnosed with brain damage due to lack of oxygen and was transferred to the neonatal intensive care unit, where he died seven days later.
Following the baby’s death, a Serious Incident Review Report was submitted and the New Zealand Ministry of Health recommended developing communication tools between midwives and obstetric units, reviewing hospital rostering, reviewing Caesarean section guidelines and proposing the opening of a second operating theatre in the labour ward.
New Zealand’s Ministry of Health offered its heartfelt condolences to the mother and her husband and assured them that care for the woman and her baby had improved.
“The staff at HNZ Waitaha [the family] What were the circumstances of their loss, especially their death? [Baby A] “It occurred,” the statement read in part.
“This incident has been devastating for all staff involved. [Mrs A] And her husband will become even more radical.”
In his report, Wall said the failures were multi-level, including a delay in assessing whether the woman needed a Caesarean section, a lack of appropriate escalation and then a delay in actually starting the operation.
Mr Wall said the decision to recommend a Caesarean section should have been made at the point when the assessment showed natural birth was not possible.
“Given the overall clinical picture, it was clear that labour was not progressing and, in my view, the decision should have been made at this point to recommend delivery by Caesarean section,” Mr Wall said.
“We already know that the decision to recommend birth by Caesarean section should have been taken much earlier, so we are concerned about the delay in starting Caesarean sections.”
Wall explained there were multiple systemic issues that affected the care the woman received, a combination of understaffing and a lack of formal procedures for escalating potentially serious incidents.
“I have taken into account the resource constraints outlined by the New Zealand Ministry of Health,” Mr Wall said. “I acknowledge those constraints but my view remains that this woman is entitled to an appropriate level of service from support staff.”
Since the incident, Health NZ has implemented several changes outlined in the report, including significant changes to staffing in obstetrics and gynaecology units.
Jeremy Wilkinson is a Manawatu-based Open Justice reporter with a legal interest covering courts and judicial issues. He has been a journalist for nearly 10 years and has worked for NZME since 2022.
