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

Introduction

1. On 15 September 2023, the Health and Disability Commissioner (HDC) received a complaint from Ms A about the care provided by Health New Zealand | Te Whatu Ora Lakes District (Health NZ). In particular, Ms A raised concerns about the management of reduced fetal movements in February 2023, shortly before the tragic stillbirth of her son, Baby A, at 41 weeks’ gestation.
   
   
2. In her complaint to HDC, Ms A also expressed concerns about Health NZ’s management of its subsequent adverse event review process, including the long delays in her receiving information about the review. Ms A described the impact this lack of communication had on her mental wellbeing.
   
   
3. HDC’s investigation has also highlighted issues with the interpretation and management of Ms A’s abnormal CTG[1] shortly before Baby A’s stillbirth and with the substandard level of clinical documentation.
   
   
4. In addition, and most significantly, the circumstances of this case highlighted systems issues with Health NZ Rotorua Lakes Maternity Service at the time of this event in 2023, with the availability and orientation of locum staff, the documentation in use, and the absence of guidelines or processes for staff to refer to for managing pregnant women all having had a bearing on the final outcome.
   
   
5. I acknowledge that, following the events, Lakes District put in place a clinical governance process with activities and follow-up to address the issues and that Health NZ undertook an external review to confirm the effectiveness of the interventions and the clinical governance process subsequently followed.
   
   
6. I extend my sincere condolences to Ms A and her family for the loss of their precious baby.
   
   

Background

7. Ms A was in her first pregnancy and had booked with her Lead Maternity Carer (LMC), Registered Midwife (RM) B, early on in her pregnancy. At the time, RM B was a recent midwife graduate, having commenced clinical practice at the start of 2022. RM B said that Ms A had a ‘normal pregnancy’ but had complained of reduced fetal movements on 1 January 2023 and again on 9 January 2023. There had also been concerns about slowing of fetal growth in January 2023.
   
   
8. RM B said that Ms A contacted her on Day1 February 2023 complaining again of reduced fetal movements. Ms A already had an appointment booked at her midwifery clinic for the following day, but because Ms A was postdates at 41 weeks’ gestation, and the concerns of reduced movements, RM B arranged for an appointment at Rotorua Hospital that day to perform a CTG.
   
   
9. Ms A arrived at Rotorua Hospital, and the CTG was commenced at 4.02pm. RM B said that the CTG showed a high baseline fetal heartrate, so at around 5.10pm she consulted the Obstetrics and Gynaecology (O&G) registrar, Dr C, who advised her to administer intravenous (IV) fluids and continue the CTG. At the time, Dr C was a junior registrar in her first year of training. Dr C needed to return to theatre and asked the O&G senior house officer (SHO), Dr D, to review Ms A. Dr C planned to review the CTG after she had returned from theatre. Neither Dr C nor RM B documented these discussions.
   
   
10. At 6.20pm, after administering fluids, RM B consulted a locum O&G senior medical officer (SMO), Dr F, who had just started his on-call shift. Dr F said that it was not an ‘entirely normal’ CTG but there were reassuring features. Dr F had received handover of patients but was leaving the hospital to attend to personal circumstances, and he asked to be phoned and updated after a further 30 minutes of monitoring to see whether the slight abnormal features would normalise. There is no documentation of this advice in the clinical notes.
    
    
11. At 7.00pm, Ms A was reviewed by Dr D, who noted the change in fetal movements and recorded her impression of fetal tachycardia. There is no mention in the clinical notes that Ms A had raised concerns about reduced fetal movements previously. Dr D documented that the CTG was borderline, so she planned to continue CTG monitoring and rediscuss with Dr F; however, there is no documentation of further discussion with Dr F having occurred.
    
    
12. RM B said that after half an hour of further monitoring, she discussed the CTG with a community LMC midwife colleague, RM E, as she was concerned about possible accelerations.[2] RM E told HDC that she considered the CTG to be normal, but the baseline heart rate was unusual. RM B said that they noted that the baseline was high (150–155bpm), but because the fetal heart rate had been on average 150bpm across the last six appointments, the high baseline ‘seem[ed] normal for this baby’. Health NZ told HDC that the CTG at 7pm showed an apparent fetal heart rate deceleration with no return to the previous baseline, and then the CTG was stopped.
    
    
13. RM B did not document the actions taken between 4.15pm and 7.00pm, but at 7.13pm she documented that she had called Dr F to advise him that the CTG had normalised, and she had relayed her discussion with RM E. RM B said that she was advised by Dr F that Ms A could be discharged with clear instructions to re-present to hospital if she experienced further reduced fetal movements.
    
    
14. Dr F told HDC that he was advised that the CTG had been reviewed by a midwife who had been trained appropriately in interpreting CTGs, and he accepted the verbal report without reviewing the CTG himself. Dr F said that he advised RM B to book an induction of labour (IOL) in the first available slot. RM B put through a request that day. Ms A was discharged home at 7.30pm without being reviewed by an SMO or resident medical officer (RMO). Ms A recalls being sent home after being told that Baby A’s heartrate was ‘not great but not bad’.
    
    
15. According to Health NZ’s subsequent Adverse Event Review (AER), the CTG performed on Day1 February 2023 was abnormal, and further medical staff review of the CTG should have occurred before Ms A was discharged home.
    
    
16. On Monday Day2 February 2023, Ms A had an ultrasound scan and was told that nothing significant had been picked up. She was booked for an induction on Wednesday Day4 February 2023.
    
    
17. On Day3 February 2023, Ms A phoned RM B to say that her waters had broken and that the fluid was green. RM B advised Ms A to attend the hospital immediately. Ms A arrived at Rotorua Hospital at 6.40am, and an initial assessment found no fetal heart rate on auscultation.[3] A bedside ultrasound confirmed that there was no fetal heart activity, and no fetal breathing or movements were detected. A formal ultrasound was performed at around 10.30am. Sadly, this confirmed that Baby A was deceased.
    
    
18. Later that day, Ms A underwent a Caesarean for malpresentation (Baby A’s brow and face were presenting).
    
    
19. Ms A was provided with inpatient postnatal care and given details of clinical follow-up, and she was advised that a formal review of her care would take place. Ms A was discharged home on Day4 February. Whilst the cause of Baby A’s death has not been found, Ms A questioned the review process and the support she received following Baby A’s birth.
    
    

Adverse Event Review

20. Ms A raised concerns about Health NZ’s AER process. She considers that better systems should have been in place for accurate and more frequent communication. Health NZ advised that the AER process commenced in March 2023. Ms A told HDC that on 14 August she received a call from Health NZ advising her that the report was nearly complete and that it would be sent to her before the staff member went on leave for two months. Ms A said that she did not receive the report, and she waited a further three weeks for any contact from Health NZ, and in all she waited eight to nine months for the completed report. Ms A said that the AER process took significantly longer than the forecast four to six months, and this had a significant impact on her mental health due to the lack of communication and the way information was communicated to her.
    
    
21. Health NZ acknowledged that the review process took longer than expected and said that this was due to the need to ensure the accuracy and completeness of the review; the amount of information that was gathered (including clinical notes and external second opinions on scans); the obtaining of statements from individuals who no longer worked there; the unexpected workload of those involved; and staff absences due to leave. Health NZ said that it sought to produce a detailed report that provided ‘critical insights and recommendations for enhancing the quality of care [it] provided’. However, Health NZ acknowledged that there were instances of miscommunication and lack of clarity on its part, and that it did not fully appreciate the potential stress and uncertainty the situation may have had on Ms A. Health NZ extended its sincere apologies for this.
    
    
22. Health NZ’s AER identified several systemic issues in the care provided to Ms A and included recommendations to address these. The following main issues were identified:

• • Ms A presented with recognised risk factors for stillbirth, including being 41 weeks’ gestation, and with a history of reduced fetal movements and borderline hypertension. Despite this, an SMO did not complete a thorough, documented review of Ms A’s CTG prior to her discharge, which was a missed opportunity for alternative management of Ms A’s care.
    
    
  • The CTG performed on Day1 February 2023 was abnormal with baseline tachycardia of above 160bpm, unprovoked decelerations, and periods of reduced variability. The obstetric registrar and locum SMO assessed this to be an abnormal CTG, and therefore further medical staff review of the CTG should have occurred before Ms A was discharged home. A hospital admission with a view to timely induction of labour may have been required to mitigate the risks. However, at the time, there was no requirement for a previously abnormal CTG to be reviewed by an obstetric registrar or SMO prior to discontinuation of the CTG and patient discharge.
    
    
  • The CTG was misinterpreted by staff, who also did not utilise the available CTG interpretation tool.
    
    
  • There is no evidence of an offer by RM B, or a request by Dr F, for the CTG to be sent to him to view electronically before deciding on the ongoing care.
    
    
  • At the time, no published clinical guideline was in place for fetal heart monitoring, nor any guideline for managing reduced fetal movements. Prior to the events, Health NZ had identified that staff required more tools to assist with CTG interpretation and that the CTG sticker tool needed to be revised to be aligned with RANZCOG[4] guidelines. The lack of guidelines was considered to have contributed to inadequate medical assessment and planning of care. The interpretation of the CTG as having normalised when it was abnormal and Ms A being discharged home without further assessment were highlighted.
    
    
  • The IOL guideline did not mention reduced fetal movements.
    
    
  • There was a lack of documentation about previous concerns relating to reduced fetal movements.
    
    
  • Reliance on locums and locum induction/orientation. There was no requirement that a locum SMO be onsite and orientating themselves to the activity in the unit or communicating with the team about the workload prior to then being based offsite.
    
    

Response to provisional opinion

Ms A

23. Ms A was given an opportunity to comment on the ‘background’ section of my provisional opinion. Ms A advised that she has no further comments, and she appreciates that her concerns have been taken seriously by HDC.

RM B

24. RM B was given an opportunity to comment on relevant sections of my provisional opinion and advised she accepts the findings. RM B’s comments have been incorporated into the report where relevant.

Health NZ

25. Health NZ was given an opportunity to comment on my provisional opinion and advised it accepts the findings.
    
    
26. Health NZ Head Office advised that maternity and obstetric staff currently have access to online or face-to-face Fetal Surveillance Program training offered by RANZCOG and, in some areas, the K2 Perinatal Training Programme delivered via online learning. This is monitored by district educators who ensure Health NZ staff are meeting annual updates and certification requirements. This training is available for LMCs with Access Agreements, free of charge.
    
    
27. Health NZ Head Office said that mandating a specific multidisciplinary educative training function requires regulatory consideration and action. Health NZ said they are also currently reviewing how they align themselves with current legislation (the Primary Maternity Services Notice 2021) and accountability for care in relation to Access Agreements and care provisions.
    
    
28. In response to the recommendations, Health NZ Head Office said it is currently putting together an update from the Maternity National Clinical Network.
    
    

Opinion: Health NZ — breach

Provision of care

29. As a healthcare provider, Health NZ is responsible for providing services in accordance with the Code of Health and Disability Services Consumers’ Rights (the Code).
    
    
30. At the outset, I acknowledge the resource-constrained environment, particularly in obstetrics services both across the country and specific to Lakes District in 2023. Health NZ told HDC that the maternity service at Rotorua Hospital at the time was experiencing a shortage of obstetric SMOs and, as a result, Health NZ was reliant on locums to cover roster gaps, including over weekends. In addition, at the time of the events, the Maternity Ward and Birthing Unit at Rotorua Hospital had been relocated together to a temporary ward area to enable renovations to be carried out.
    
    
31. However, these factors do not diminish the responsibility of Health NZ to ensure that appropriate protocols were in place to guide staff and LMCs in their decision-making and in their provision of maternity care. As acknowledged by Health NZ in its AER, at the time of these events there were no guidelines or processes for staff and LMCs to refer to for management of reduced fetal movements, no guidelines for fetal heart monitoring, and no up-to-date CTG interpretation tool available for staff and LMCs.
    
    
32. I acknowledge that RM B (and her LMC colleague), who incorrectly interpreted Ms A’s CTG on Day1 February 2023 as having normalised, were community LMC midwives not employed by Health NZ. However, RM B was providing services to Ms A in consultation with Health NZ clinical staff, and RM B was acting in accordance with Health NZ’s guidance. It is clear that RM B was not working in isolation or in ways that were inconsistent with Health NZ’s policies or processes (noting the absence of these described above).
    
    
33. In my opinion, the lack of relevant policies and guidelines in the maternity service at the time impacted on the decisions made about Ms A’s care. I hold Health NZ responsible for these systemic failings. Accordingly, I find that Health NZ breached Right 4(1) of the Code for failing to provide services to Ms A with reasonable care and skill.
    
    
34. Health NZ has implicitly acknowledged and addressed the shortcomings in the guidance material it has since developed for the maternity service. The material applies to hospital clinical staff and LMCs who have an access agreement (as was the case for the LMC in this situation).
    
    

AER process

35. Ms A also raised concerns about the AER process, in particular the communication with her and the time taken to complete the review. I acknowledge the concerns raised by Ms A in this respect, particularly considering the enormity of the event and the sudden and unexpected loss of her son. Having reviewed Health NZ’s AER, I am satisfied that an extensive investigation was conducted by Health NZ and that the review identified areas for improvement.
    
    
36. Despite the thoroughness of the review, I encourage Health NZ to reflect on Ms A’s experience and ensure that in future there is transparency throughout the AER process, particularly when there are unexpected delays.
    
    

Opinion: RM B — adverse comment

37. As part of my investigation, I sought in-house clinical advice from Midwifery Advisor Nicholette Emerson (Appendix A) about the care provided by RM B. I am critical of certain aspects of RM B’s care in relation to her standard of documentation and her management of an abnormal CTG.
    
    

Documentation

38. Ms A had complained of reduced fetal movements on 1 January and 9 January 2023. Whilst RM Emerson advised that the antenatal care provided by RM B met accepted midwifery standards, with all routine clinical assessments and investigations having been undertaken and evidence of appropriate midwifery response to reduced fetal movements, RM Emerson advised that the ‘clinical narrative is minimal’ in the clinical records and that the documentation on Day1 February 2023 does not detail that this was Ms A’s third presentation for reduced fetal movements and does not record the care she provided between 4.15 and 7pm or her consultations with her colleagues. I accept RM Emerson’s advice and agree that RM B’s documentation lacks sufficient detail to provide a complete clinical picture of the care provided. I encourage RM B to reflect on RM Emerson’s comments, and I have made recommendations in this respect.

CTG interpretation

39. Health NZ’s AER identified that the CTG performed on Day1 February 2023 was abnormal and therefore further medical staff review of the CTG should have occurred before Ms A was discharged home. RM Emerson is critical that RM B removed the CTG without first consulting an obstetrician. I accept this advice and agree that Ms A should not have been discharged without medical review. However, my criticisms of RM B’s actions are mitigated for the following reasons:

1. 1. I am aware that RM B consulted with another more experienced midwife regarding the interpretation of the CTG, and she received verbal acceptance on the phone from Dr F to discharge Ms A;
      
      
   2. Significantly, and as reflected in the AER, there were several systemic issues with the Health NZ Rotorua Lakes Maternity Service at the time, with the lack of policies and guidelines having some bearing on the decisions taken by RM B and other clinical staff, and this led to inadequate medical assessment and planning of care.

Concluding remark — CTG monitoring/interpretation

40. As noted in this report, Health NZ’s AER highlighted issues with the interpretation and management of Ms A’s abnormal CTG shortly before Baby A’s stillbirth. It is important to recognise that inadequate CTG monitoring/interpretation has featured consistently as one of the most common issues seen in the more serious maternity-related complaints investigated by HDC over time.
    
    
41. HDC has repeatedly advocated for further work to be undertaken at a national level to implement mandatory multi-disciplinary fetal surveillance training. Unfortunately, this training has still not been implemented consistently across Aotearoa.
    
    

Changes made

Health NZ

42. Health NZ said that since the events it has implemented the following changes:

• A clinical guideline on decreased fetal movements has been developed, and staff (including LMCs) have been educated about the content of the guideline and how to access it.
• The Lakes Fetal Heart Monitoring Guideline has been developed, and the CTG Interpretation Tool (sticker) has been updated, and staff have been advised of the availability of these documents. The documents are accessible to staff, and they have been incorporated into staff education sessions.
• The Fetal Heart Monitoring Guideline has been updated to state that any abnormal CTG for which previous consultation has been sought must be sighted by an Obstetrics registrar or SMO prior to patient discharge.
• The locum SMO contract wording has been revised to include that any SMO providing locum cover is required to be available and present for at least two hours from the commencement of their shift. This has been communicated to all locum SMOs currently contracted and is communicated to any subsequently contracted locum SMOs.
• The Induction of Labour Booking Request Form has been amended to include ‘Reduced Fetal Movements’ and a prompt for staff to indicate the number of presentations with reduced fetal movements. Staff have been made aware of the changes, and the updated form is now in use.
• The Induction of Labour Guideline has been reviewed and revised in line with the new national guidance and made available to staff, who have been educated on its content. The new guideline includes reference to reduced fetal movements as a possible indication for induction of labour.

RM B

43. RM B said that following these events she carried out a personal reflection of the care she provided as the LMC. RM B stated that she is now vigilant in ensuring that even if the specialist is not onsite, they are given a copy of the CTG. RM B said that she will continue to consult and seek the advice of other midwives when interpreting CTGs, but will ultimately follow her own judgement if that is what she feels is the correct course of action.
    
    
44. In addition, RM B said that in July 2023 she completed the Fetal Surveillance Education Program online training, and she plans to undertake a documentation workshop.
    
    

Recommendations and follow-up actions

45. I recommend that Health NZ provide a written apology to Ms A and her family for the failings identified in this report. The apology should be provided to HDC, for forwarding to Ms A, within three weeks of the date of this report.
    
    
46. I recommend that Health NZ evaluate the effectiveness of the new and updated policies implemented as a result of its AER by conducting an audit of compliance and provide HDC with the outcome report of any corrective actions to be implemented, within six months of the date of this report.
    
    
47. I recommend that RM B complete the ‘Dotting the I’s in a digital age: Record keeping for midwives’ workshop offered by the New Zealand College of Midwives, or an equivalent professional development course in relation to clinical documentation. Evidence of completion is to be provided to HDC within six months of the date of this report.
    
    
48. 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. I take this opportunity to request an update from Health NZ’s National Chief Midwife on the Network’s current priorities and will reinforce the importance of the Network progressing the implementation of mandatory multi-disciplinary fetal surveillance training.
    
    
49. A copy of this report with details identifying the parties removed, except Health NZ Lakes District, Rotorua Hospital, and the advisor on this case, will be sent to the Perinatal and Maternal Mortality Review Committee and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

Rose Wall

Deputy Health and Disability Commissioner