Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

1. On 13 September 2022, the Health and Disability Commissioner (HDC) received a referral from the Nationwide Health and Disability Advocacy Service regarding the care provided to Mrs A and Baby A by Health New Zealand | Te Whatu Ora Hauora a Toi Bay of Plenty (Health NZ). On Day2 April 2022, Mrs A gave birth to Baby A who was born in a poor condition and sadly passed away 22 hours after birth. I express my sincerest condolences to Mrs A and her husband, Mr A, for their profound loss.
   
   
2. This report considers the key issues that Mrs A raised about the care she and Baby A received on Day2 April 2022.
   
   
3. Mrs A, in her response to the provisional report, said that she wanted a safer Aotearoa for future mothers and pēpi. I fully support Mrs A’s sentiment and agree that learnings must be taken from this family’s tragic experience and acted upon to remedy the shortcomings in care highlighted in this report. The findings from this investigation will be shared with relevant agencies with the aim of giving further attention to the challenges facing our current maternity system.
   
   

Information gathered

4. At the time of the events, Mrs A was aged 29 years and was pregnant for the first time as a result of in vitro fertilisation.[1] Mrs A presented to Tauranga Hospital on 7 February 2022 and 25 March 2022 because of reduced fetal movements. On Day1 April 2022, Mrs A requested an induction of labour because she was concerned that she could not monitor fetal movements while she was experiencing severe migraines. Induction of labour was planned for Day3 April 2022.

Initial presentation

5. At 8.04am on Day2 April 2022 (at 40 weeks and 2 days’ gestation), Mrs A called her lead maternity carer (LMC) registered midwife (RM) B with concerns about an absence of fetal movements since midnight and intermittent pain. As RM B was attending another patient, she advised Mrs A that her back-up, RM C,[2] would meet her at the hospital.
   
   
6. At around 9am, Mrs A presented to Tauranga Hospital’s maternity unit. At 9.20am, Mrs A was admitted to hospital but remained under the care of her LMCs. RM C checked Mrs A’s maternal observations[3] and completed a physical examination. The observations were normal, but RM C documented that Mrs A’s abdomen was ‘tight’ on palpation, she had severe pain, and that there were no fetal movements or vaginal bleeding.
   
   
7. Cardiotocography (CTG)[4] monitoring was commenced at 9.26am, and the fetal heart rate was noted to be 145 beats per minute (bpm) with reduced variability[5] and no accelerations[6] or decelerations[7] (which is an abnormal CTG finding). RM C completed a stretch and sweep[8] and repositioned Mrs A to help improve the CTG. However, the variability did not improve. Mrs A remained on continuous CTG monitoring until Baby A’s birth (discussed further below).
   
   
8. As the CTG was abnormal, RM C sent a photo of the CTG trace to RM B and requested a medical review from the obstetrics and gynaecology registrar, Dr D, at 10am. RM C said she had a discussion with Dr D in the corridor outside Mrs A’s room (Mrs A was not present) and explained the situation, providing Mrs A’s history, including that she had not experienced any fetal movements since midnight, that she had a tight abdomen, and that RM C was unable to palpate the baby’s position.
   
   
9. Health NZ completed an adverse event report (AER) into the care provided to Mrs A and Baby A, which noted that assessments and discussions of concerns should take place in the presence of the consumer and that, if consultation is required, this is to be completed with the consumer. The AER found that ‘corridor conversations’ and advice were frequently sought from clinicians without assessment or advisement of the full clinical situation.
   
   

Initial medical review

10. Dr D assessed Mrs A at 10.20am and noted that the CTG had reduced variability with no decelerations and that it had a stable baseline. She recorded that Mrs A’s abdomen was soft and not tender and that there was intermittent lower abdominal tightening and no vaginal bleeding. This was documented retrospectively as Dr D stated it was an ‘incredibly busy shift’. In contrast to Dr D’s assessment and documentation, Mrs A told HDC that Dr D had barely felt her ‘woody abdomen’ even though RM C had alerted her to this, that she had informed Dr D about a sharp pain and a burning, tearing sensation and absence of fetal movements before leaving home, and that she did not get a chance to fully discuss her concerns with Dr D. In response to the provisional opinion, Mrs A said that her husband and her mother had also noted her stomach as being hard.
    
    
11. Following the medical review, Dr D made a plan for RM C to monitor the CTG for a further 30 minutes to see whether the variability improved, and then another medical review would be completed after this period. Dr D said this plan was made given that everything other than the variability was reassuring and that the CTG suggested that the fetus was in a sleep cycle.
    
    
12. Following the initial review and before the management plan was implemented, Dr D called the Senior Medical Officer (SMO), Dr E, to discuss the situation. Dr E agreed with the management plan. Dr E said Dr D had advised her that Mrs A had a CTG trace with reduced variability but no accelerations or decelerations and that her plan was to reposition, offer fluids, and re-review Mrs E in 30 minutes. The CTG trace was not shown to Dr E, nor did she request to see it. RM C told HDC that, in hindsight, because of the abnormal CTG trace, she wished she had not accepted Dr D’s plan to re-review in 30 minutes.
    
    
13. The AER found that the CTG had been misinterpreted,[9] that it indicated fetal distress, and that this should have triggered immediate management or urgent delivery. Therefore, Dr D should not have made a 30-minute monitoring plan. Health NZ said immediate management includes identification of any reversible causes of the abnormality, consideration of further fetal evaluation or delivery if significant abnormality persists, and escalation of care to a more experienced practitioner. However, this did not occur.
    
    
14. Although RM C and Dr D documented the CTG abnormalities in the obstetric clinical notes, they did not use the CTG interpretation sticker[10] to interpret the trace or document the plan, as required by Health NZ’s Antenatal Fetal Heart Rate (FHR) Monitoring Policy (dated 2021).
    
    

Actions taken after lack of follow-up by Dr D

15. Despite planning to re-review Mrs A within 30 minutes, Dr D did not return because she was attending an emergency. Dr D did not inform another staff member about the need to review Mrs A in 30 minutes.
    
    
16. Health NZ said that, on Day2 April 2022, there were three emergencies, two staff members had called in sick, and the maternity service had a deficit of nine full-time RMs. Health NZ said the delivery and maternity suites were placed in code yellow (and later orange) in the variance response management system,[11] which is overseen by the operations centre, to indicate that there were concerns regarding capacity and resource availability. Health NZ did not state what support was offered by the operations centre.
    
    
17. The AER found that, despite the staffing shortages on the day, the obstetrics and gynaecology team did not call for additional obstetric support. The AER states there was an option to escalate resourcing issues during the daytime hours to a second obstetrician on site or, alternatively, the gynaecology registrar, although this would have required the midwifery coordinator to review the staffing roster.
    
    
18. As the CTG trace remained non-reassuring and Dr D did not return to re-review Mrs A, RM C left Mrs A’s room at around 11am to find Dr D. Mrs A said RM C left the room many times to try and get help. RM C could not find Dr D or the midwifery coordinator and was advised by Health NZ midwife, RM F, that Dr D was busy with an emergency and to call her. Although Health NZ agreed that RM C could not easily obtain obstetric advice, it said that Dr D could have been contacted by phone (even in an emergency) and that this did not occur.
    
    
19. RM C acknowledged that she could have called Dr D and that she did not do so because she had been advised that Dr D was attending an emergency and because the CTG trace had not deteriorated and had remained consistent since admission. In addition, RM C did not attempt to call the midwifery coordinator, who at the time was also attending an emergency, or call the 777-emergency bell for support. Health NZ said that the phone numbers of the midwifery coordinator, registrar, and other senior staff, such as the duty manager and midwifery director, were displayed at various places around the obstetrics and gynaecology ward. No hourly progress updates in relation to Mrs A were written on the unit whiteboard to alert other staff to concerns or to allow them to assist with follow-up. It is not known whether RM C was aware of the escalation pathway at the time.
    
    
20. As RM C was unable to find Dr D, she showed RM F a picture of Mrs A’s CTG trace on her phone. RM F advised RM C to move Mrs A to an antenatal room (near the delivery suite) and commence intravenous fluids. RM C said she completed this at 11.30am; while doing so, she advised Mrs and Mr A of the possibility that induction might be brought forward. RM F said she was later called to an emergency. She was with this patient for 1.5 hours and did not see RM C again. The AER found that this meant no formal midwifery consultation had occurred.
    
    

Second medical review

21. At 11.51am, RM C handed over Mrs A’s care to another Health NZ midwife, RM G, as she was unable to find the midwifery coordinator. RM C explained that she was waiting for a registrar review because of the abnormal CTG. RM G said she went straight to Mrs A’s room to check the CTG. After reviewing the CTG, she removed the printout to show to another obstetrics and gynaecology registrar, Dr H, who was in the staff office. Dr H recalled that he was not rostered for acute duties but came to help as he had heard that the delivery suite was busy.
    
    
22. Dr H arrived in Mrs A’s room at 12.10pm. He said he completed an assessment, examined Mrs A’s abdomen for signs of placental abruption,[12] and noted that she had some mild back pain. He also found the CTG very concerning and said he was unaware that Dr D had completed a registrar assessment earlier in the day. He then completed a bedside ultrasound scan. Health NZ said the ultrasound was unnecessary in the context of continued CTG monitoring that had indicated fetal compromise. The scan showed that the liquor volume (the amount of amniotic fluid) was normal and the presence of meconium[13] in the liquor (a possible sign of fetal distress). Following discussion with the consultant[14] at 1.10pm, Mr H advised Mrs A that she would require a caesarean section.
    
    
23. The request for a caesarean section was made with category 2 urgency (to be completed within 60 minutes). The AER noted that the caesarean section should have been classified as category 1 (urgent) as the CTG had remained unchanged from the initial presentation to the maternity unit at approximately 9am. Health NZ stated that, had a category 1 caesarean occurred within the hour of presentation to the hospital, it would have ‘significantly improved the outcome for Baby A and may have prevented his death’.

Baby A

24. Mrs A was taken to theatre at 2.05pm, and Baby A was born at 2.35pm on Day2 April 2022. He was born covered in blood and in a critical condition, including aspiration of blood into his lungs and stomach, requiring artificial ventilation and care in the Neonatal High Dependency Unit. The AER noted that a partially concealed placental abruption may have occurred in the early hours of the morning on Day2April 2022, which was suspected by the obstetric team, who identified a blood clot behind the placenta and blood-stained liquor.
    
    
25. Specialist advice was sought from Tauranga Hospital paediatric intensivists and paediatric consultants, the Waikato Hospital neonatal retrieval team, and Waikato Hospital neonatologists. The AER found that the decision-making around Baby A’s care after delivery was the best it could have been at the time, and his medical management did not require any changes to be made in this respect.
    
    
26. However, the AER highlighted concerns with the retrieval and transport team involved in Baby A’s care. As Baby A was born in a critical condition, he was initially on a pathway to be transferred to Waikato Hospital, which had been requested to retrieve him.
    
    
27. The retrieval team from Waikato Hospital was expected to arrive at Tauranga Hospital at 6pm; however, the helicopter could not land at the hospital because of poor weather conditions and had to divert to Tauranga Airport. Ambulance transport was then required from Tauranga Airport to Tauranga Hospital. The AER found that, although the weather conditions were out of their control, there was a delay in getting the retrieval team from the airport to the hospital because the ambulance was not configured to accommodate the transport incubator (which is only compatible for right-handed loading ambulances).[15] The AER found that, when ordering the ambulance, the configuration requirements need to be specified, which did not occur in this case. The AER also found that there was a small opportunity for transfer by ambulance from Waikato to Tauranga; however, this would not have affected the outcome in this case.
    
    
28. Unfortunately, Baby A deteriorated while waiting for the retrieval team and was redirected to palliative care. Sadly, Baby A passed away 22 hours after his birth at 12.18pm on Day3 April 2022. Information provided by ACC indicated that there was a total delay of around 3.5–4 hours, but the AER noted that there was a delay of over five hours in delivering Baby A and that this delay likely contributed to his death.
    
    

Bereavement support

29. Mr and Mrs A expressed that the bereavement support they were provided was poor and that they felt unsupported by maternity staff. The AER also found deficiencies in the bereavement support provided to the family. Health NZ said that initial support was provided to the family by a bereavement midwife on Day3 April 2022. It is not known what other support was provided on the day of Baby A’s death. Further, a social worker review occurred on Day4 April 2022, which noted that referrals had been completed to grief support services and Bellyful.[16] In addition, Mr and Mrs A were advised that they could contact the social worker if they needed further assistance. It is not known whether Mr and Mrs A sought further assistance from the social worker. Finally, ACC forms were completed post-discharge for ongoing counselling funding.
    
    

Clinical advice

30. In-house midwifery advice was sought from RM Nicholette Emerson (Appendix A), who advised that there was a moderate departure from the accepted standard of care with respect to RM C not contacting Dr D when the re-review was due. However, RM Emerson noted that this was mitigated by the ongoing obstetric emergencies and the lack of a clear pathway to escalate concerns.
    
    
31. Clinical advice provided to ACC by obstetrician and gynaecology professor, Dr I, states that the CTG pattern initially assessed by Dr D was very concerning in the absence of fetal movements and that Dr D should have recognised that during her initial assessment. Dr I also advised that the CTG appearance was consistent with severe hypoxia (low oxygen levels) of 12 hours or more.
    
    

Responses to provisional report

32. Mrs A, Health NZ and RM C were provided with a copy of the provisional report for comment.
    
    
33. Mrs A appreciated the work undertaken by the HDC. She emphasised that the failures in the care provided to her and Baby A have changed her family’s lives forever and that these events have caused ongoing harm. Mrs A’s comments have been incorporated into this report.
    
    
34. Health NZ said it accepted that it did not provide services to Mrs A and Baby A with reasonable care and skill. Other comments made by Health NZ have been incorporated into this report where relevant.
    
    
35. RM C accepted the decision and provided an apology to Mrs A for the deficiencies in her care, as per my proposed recommendation in the provisional decision.
    
    

Decision

Health New Zealand | Te Whatu Ora – breach

36. As a healthcare provider, Health NZ has a responsibility to ensure that it provides care in accordance with the Code of Health and Disability Services Consumers’ Rights (the Code). Right 4(1) of the Code states: ‘Every consumer has the right to have services provided with reasonable care and skill.’ After carefully reviewing all the information on file, including the clinical notes, the parties’ responses, and Health NZ’s comprehensive AER, I consider that Health NZ did not provide a reasonable standard of care to Mrs A.
    
    
37. The AER highlights a series of failures in Mrs A’s care. This includes the staffing inadequacies, a lack of clear escalation pathways, a lack of consistent use of CTG interpretation stickers, failure to initiate immediate management or urgent delivery following the initial and second medical review, the practice of undertaking ‘corridor conversations’, inadequate bereavement support, and inadequate communication with the ambulance dispatch team. I have reviewed these findings in conjunction with the other information before me, and I agree with them. In my opinion, these deficiencies cumulatively resulted in Mrs A receiving a poor standard of care. As these deficiencies were a result of actions taken by multiple providers, I consider this to be a system failure. Accordingly, I find that Health NZ breached Right 4(1) of the Code. I note that Health NZ has apologised to the family for the care provided to Mrs A.
    
    
38. After review of the clinical notes, it is clear that urgent intervention was warranted when Dr D initially reviewed the CTG and, equally, when Dr H subsequently reviewed it. I am concerned that neither of the registrars recognised the serious fetal distress they were observing on the CTG trace or responded accordingly.
    
    
39. In my opinion, the main issue is the delay that led to Baby A being born in a critical condition, rather than the care that he received after delivery. I agree with the AER that the decision-making around Baby A’s care after delivery was sound. Therefore, I am not critical of the care provided to Baby A.
    
    

RM C – adverse comment

40. RM C was the LMC caring for Mrs A when she initially presented to Tauranga Hospital on Day2 April 2022. RM C initiated CTG monitoring when Mrs A told her that she felt there had been reduced fetal movements. RM C recognised the abnormal CTG trace and appropriately escalated this to the obstetrics and gynaecology registrar, Dr D, who reviewed Mrs A and suggested monitoring for 30 minutes and a further medical review after this. The key issue to be determined is whether RM C took reasonable steps to escalate Mrs A’s care when Dr D did not return to re-review her after the planned 30 minutes.
    
    
41. I note that RM C left Mrs A’s room many times to seek medical assistance and, when she was unsuccessful, escalated Mrs A’s care to Health NZ midwife RM F, who advised RM C to call Dr D. RM C expresses regret over not calling Dr D; however, she noted that the CTG trace had not changed and that Dr D was attending an emergency. I also note that, at this time, RM C was unable to locate the midwifery coordinator, who had the responsibility of overseeing the care in the maternity unit.
    
    
42. In my opinion, this was a situationally challenging context. Although the responsibility to complete the medical review lay with Dr D, it was also RM C’s responsibility to ensure that this plan was followed through. I am critical that RM C did not follow RM F’s advice to call Dr D.
    
    
43. However, in mitigation, I also accept RM Emerson’s advice that RM C was aware that Dr D was attending another emergency. Under these circumstances, it is essential that there is a clear escalation pathway, which was Health NZ’s responsibility to implement, as discussed above. In addition, I note that Dr D does not appear to have sought the support of her colleagues to follow up with Mrs A when she was attending another emergency and was unable to attend Mrs A herself after the planned 30 minutes.
    
    

Changes made

Health NZ

44. Health NZ apologised to the family for the care it provided. It has made the following changes to improve its practice since these events:

1. 1. A ‘fresh eyes review’ was introduced in June 2022. This requires a practitioner caring for a patient to seek a colleague’s review of the CTG trace, along with the patient’s full clinical picture every hour to decide on the appropriate management plan.
      
      
   2. A maternity forum centred around Mr and Mrs A’s experience was held in November 2022. This forum was used to help staff understand the impact of grief, bereavement, and adverse event support.
      
      
   3. Staff were reminded to provide details around configuration requirements when dispatching ambulances.
      
      
   4. The CTG from this incident was reviewed during the weekly CTG education session and discussed at the perinatal morbidity and mortality meeting.
      
      
   5. The use of the CTG sticker was reviewed.
      
      
   6. The maternity leadership team now holds a bi-monthly meeting with LMCs to discuss concerns and provide other updates.
      
      
   7. Adverse event escalation pathways have been discussed with LMCs.
      
      
   8. Discussions have been held between maternity coordinators and LMCs to address concerns regarding corridor conversations and advice being sought without understanding the patient’s full clinical picture.
      
      
   9. Education requirements of staff have been reviewed. Following this review, Health NZ has reimplemented weekly CTG education sessions, and LMCs were invited to attend these.
      
      
   10. A computerised CTG analysis was introduced and made available to obstetricians under specific circumstances, and Health NZ intends to purchase more replacement CTG machines that include this feature.
       
       
   11. BadgerNet (an electronic clinical record system) has been implemented so that clinicians can view CTGs from a phone or computer. As part of this, the use of CTG stickers has been discontinued.
       
       
   12. A recommendation has been made to the obstetric team that a department-wide flowchart be developed to show a clear process for LMCs and midwives to follow when staff are attending multiple emergency events.
       
       
   13. An additional obstetrician is being recruited.
       
       
   14. LMCs and midwives now update the maternity unit whiteboard with patient information and progress updates hourly.
       
       
   15. The Maternity National Clinical Network is progressing the implementation of mandatory multi-disciplinary fetal surveillance training, and the associated regulatory
       requirements are being actively reviewed to ensure accountability and consistency across New Zealand.
       
       

RM C

45. The Midwifery Council of New Zealand completed a competence review in relation to RM C and deemed that she was practising midwifery to the standard of competence reasonably expected of a midwife.
    
    
46. RM C expressed her sincerest condolences to the family and has made the following changes to her practice:
    1. She has completed two fetal surveillance education programme workshops run by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
    2. She now escalates care to senior midwifery staff and obstetric colleagues if a CTG is abnormal.
       
       

Recommendations

Health NZ Hauora a Toi Bay of Plenty

47. In addition to the improvements outlined above, I recommend that Health New Zealand | Te Whatu Ora Hauora a Toi Bay of Plenty:
    
    
    1. Report on the effectiveness of its implementation of electronically recorded CTGs via BadgerNet integration within three months of the date of this report;
       
       
    2. Report on the effectiveness of its implementation of a computerised Dawes-Redman algorithm to aid with the interpretation of CTGs and to support obstetricians with clinical management under specific circumstances within three months of the date of this report;
       
       
    3. provide an update on the development of the department-wide escalation flowchart within three months of the date of this report;
       
       
    4. provide an update on the staffing levels in the maternity ward and the obstetrics and gynaecology team, including whether any further recruitment is being undertaken, within three months of the date of this report;
       
       
    5. audit the percentage of Health NZ midwives and members of the obstetrics medical team attending the weekly CTG education sessions. A summary of the findings, with any corrective actions to be implemented, is to be provided to HDC within three months of the date of this report.
       
       

Follow-up actions

48. A copy of the sections of this report that relate to RM C will be sent to the Midwifery Council of New Zealand.
    
    
49. A copy of this report with details identifying the parties removed, except Health New Zealand | Te Whatu Ora Hauora a Toi Bay of Plenty, Waikato Hospital, Tauranga Hospital, and the clinical advisor, will be sent to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and to the Perinatal and Maternal Mortality Review Committee and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
    
    
50. In early 2025, Health NZ established a Maternity National Clinical Network (the Network) to provide national leadership and oversee the strategic direction, strategic priorities, and programme of work for maternity services across Aotearoa, including the development of national standards and models of care. A copy of this report, with details identifying the parties removed, except Health New Zealand | Te Whatu Ora Hauora a Toi Bay of Plenty, Waikato Hospital, Tauranga Hospital, and the clinical advisor, will be sent to Health NZ’s National Chief Midwife to further reinforce the importance of the Network progressing its strategic work programme as a priority.
    
    

Rose Wall

Deputy Health and Disability Commissioner