Waikato District Health Board (DHB) (now Te Whatu Ora
Waikato) breached the Code of Health and Disability Services
Consumers’ Rights (the Code) for not providing services with
reasonable care and skill to a pregnant woman.
While
she was 12 weeks pregnant with twins, the woman first
presented to the hospital’s emergency department with
headaches and nausea. She required acute management of early
onset hypertension.
At the time there, was no
effective plan in place to monitor the woman’s pregnancy
in the community on an ongoing basis. The woman was later
admitted to hospital with intrauterine growth restriction,
as one of the twins had an abnormal heart rate. The woman
remained in hospital until the delivery of her
babies.
It was subsequently confirmed that only one
foetal heartbeat was present, and the woman was told that
one of her babies had passed in utero. That same day the
twins were delivered by emergency caesarean section. While
attempts to resuscitate one of the twins were unsuccessful,
the other baby was born in good condition.
The woman
stated that when she learned one of her babies had died, she
told medical staff she needed to ensure they had whānau to
care for them while she was unable to. Whānau were not
notified, nor was a cultural support person sourced to be
with the woman (who is Māori) while she worked through the
immediate aftermath of losing her baby.
Rose Wall,
Deputy Health and Disability Commissioner, found Waikato DHB
breached Right 4(1) of the Code, which gives consumers the
right to have services provided with reasonable care and
skill.
Ms Wall accepted the circumstances were
challenging, but the cumulative deficiencies in the care
provided amounted to the breach.
She was critical of
Waikato DHB’s care following the first ED review when an
effective plan was not put in place to closely monitor the
woman’s condition in the community. She was also critical
that medical input was not sought when two separate
heartbeats could not be identified clearly, and of the
decision over whether to deliver the babies early.
Ms
Wall recommended Te Whatu Ora Waikato provide a written
apology, train staff on the management and monitoring of
hypertension and pre-eclampsia in twin pregnancies, and
provide HDC with a copy of its cultural/kaupapa training
framework, outlining how the practice of tikanga with
patients and their whānau is developed with all hospital
staff.
Editors notes
Please only use the photo
provided with this media release. For any questions about
the photo, please contact the communications team.
The
full report of this case can be viewed on HDC’s website –
see HDC’s ‘ Latest
Decisions‘.
Names have been removed from the
report to protect privacy of the individuals involved in
this case.
The Commissioner will usually name
providers 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. More information for the media,
including HDC’s naming policy and why we don’t comment on
complaints, 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).
In 2022/23 HDC made 592 quality improvement
recommendations to individual complaints and we have a high
compliance rate of around 96%.
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