The blocked caller mode was one in a series of failures, including those of a doctor and Health New Zealand Te Whatu Ora, identified by the Health and Disability Commissioner following a complaint from the baby’s father about the antenatal care provided to his wife at Waitākere Hospital.

In a decision released today, Deputy Health and Disability Commissioner Rose Wall extended her condolences to the couple for the loss of their daughter.

Wall said while it was not possible to know if the outcome might have been different had the calls not been blocked, she critical that the hospital bedside telephone system did not work.

“I consider that this was a barrier to the provision of timely and safe services.”

Wall found Health NZ breached a section of the health consumers’ code, through failing to ensure care was managed in a way that was safe and appropriate.

She found intermittent cardiotocography (CTG) monitoring was also not carried out as required in the circumstances, largely because of the consultant obstetrician’s busy workload, which resulted in compromised communication about the care plan.

Mother in early labour on arrival at hospital

The mother, then aged in her late 20s, arrived at Waitākere Hospital on an undisclosed date for assessment at 40 weeks and three days’ gestation.

Wall said she was in early labour and reported reduced fetal movements.

Cardiotocography, which continuously monitors the fetal heart rate and uterine contractions, recorded reduced movement two days earlier.

When the woman returned to the hospital, monitoring was considered “abnormal” as there was an absence of fetal heart rate accelerations and, initially, a couple of shallow decelerations.

The consultant obstetrician did not think it was indicative of fetal hypoxia (reduced oxygen supply to a baby in utero), and recommended continued CTG monitoring.

Wall said there were no concerns reported for the baby. The midwife had told the doctor that the mother’s antenatal scans at 31 and 35 weeks’ gestation were normal and that a further scan was to be done in a few days’ time.

However, the doctor mistakenly understood that a scan had been undertaken days before, with normal findings.

Care handed to midwife

An hour after the mother arrived back in hospital, her care was handed over to the midwife, who told the couple how to use the bedside telephone to contact her directly if they had any concerns.

A little over an hour and a half later, the doctor reviewed the monitoring trace and concluded that although the CTG was abnormal, there was nothing to indicate fetal hypoxia.

The doctor spoke with the midwife at 10.30pm and said that in the hours following she was involved in the care of “one woman after another”.

Wall said Waitākere Hospital’s policy at the time was for a second obstetrician to be called if two obstetric interventions were required concurrently.

The doctor said that although it was a busy night, the interventions required were sequential, so a second obstetrician was not called.

The doctor later told the Health and Disability Commissioner she did not feel there was enough evidence to warrant an emergency caesarean delivery, but she wanted to continue observations.

The midwife saw the mother a few times throughout the night.

The father recalled that he and his wife conveyed their concerns for the baby’s wellbeing to the midwife, including reduced fetal movements, and requested monitoring be recommenced.

Wall said the midwife’s recollection suggested she was not told of any concerns aside from the mother mentioning that she had blood spotting.

Monitoring did not restart until 6.50am.

Wall said no fetal heartbeat could be found and it was confirmed the baby had passed away.

‘Differing’ accounts from midwife and doctor

She said there were differing versions between the doctor and the midwife of events as to why CTG monitoring was not repeated overnight, but in the end she found the midwife’s account more compelling.

An Adverse Event Review (AER) by Health New Zealand Te Whatu Ora Waitematā noted they presented “materially different” versions of events, Wall said.

The review identified, among a list of things, that while the CTG was not indicative of fetal hypoxia, monitoring should have been repeated overnight.

Wall said it was alarming the doctor appeared to have been dealing with responsibilities beyond one senior medical officer’s capacity.

She said it was clear from the doctor’s response and Health NZ’s review of the adverse event that CTG monitoring should have been repeated overnight.

“I am critical that this did not occur.”

Wall said because the doctor was responsible for the mother’s care planning, which was inappropriate, the doctor had to bear some responsibility for the failure.

However, this was mitigated by Health NZ’s failure to ensure the doctor was adequately supported to call in a second senior medical officer.

Wall said it was Health NZ’s responsibility to ensure that sufficient levels of skilled and experienced staff were in attendance to ensure the provision of safe, timely and competent care.

Her recommendations included that the call-blocking function was to be deactivated on all telephones used by women/couples to contact staff and to confirm if there have been any further instances of blocked calls since the events that led to the complaint.

The commmissioner was also to be given a copy of the hospital’s updated policy or guidance on the threshold for calling in a second on-call obstetrician.

Wall also recommended it consider amending its reduced fetal movements policy to include maternal ethnicity as a risk factor for stillbirth.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.