Director of Proceedings v Burne-Vaughn [2026] NZHRRT 30
(9 September 2026)
The Director filed proceedings by consent in the Human Rights Review Tribunal (the Tribunal) against RM Burne-Vaughn, a registered LMC midwife, regarding the care she provided to the aggrieved person and her baby, which was stillborn. The case involved multiple departures from accepted midwifery standards relating to aspects of RM Burne-Vaughn’s antenatal care, her management of the aggrieved person’s labour, her postnatal care including her role in the resuscitation process, and her clinical documentation.
Antenatally, RM Burne-Vaughn did not see the aggrieved person between 26 and 35 weeks’ gestation in accordance with accepted midwifery practice, to monitor for things like fetal growth and complications. Her clinical documentation of antenatal visits was minimal and included no commentaries of any discussions had or information given to the aggrieved person and did not contain the first trimester and 20-week anatomy scan reports. RM Burne-Vaughn did not order 28-week bloods as per expected practice to check for gestational diabetes and the aggrieved person’s full blood count and iron stores. RM Burne-Vaughn also failed to record a clinical reason for ordering a 29-week growth scan, and to follow up on the marginal cord insertion showing on the scan.
During labour, RM Burne-Vaughn did not take baseline maternal observations (including heart rate, temperature, and blood pressure) or four-hourly observations as expected and failed to record the onset of second stage of labour accurately. She did not conduct fetal heart rate (FHR) monitoring at expected intervals, she did not palpate the maternal and fetal heart rates simultaneously to differentiate between them, and she failed to notice the apparent dropping FHR baseline. Further, RM Burne-Vaughn failed to keep adequate contemporaneous notes during the aggrieved person’s labour and recorded all her clinical notes retrospectively.
After baby was delivered with no signs of life, RM Burne-Vaughn did not alert other midwives of an emergency and failed to have resuscitation equipment set up before the birth to manage an emergency. RM Burne-Vaughn rubbed the baby to stimulate him for approximately six minutes before the arrival of other midwives. Accordingly, there was a delay between delivery and the commencement of resuscitation. Given the condition baby was in, accepted practice would have been to provide stimulation for 20 to 30 seconds, but when this was unsuccessful RM Burne-Vaughn should have called for help immediately and commenced resuscitation.
Postnatally, RM Burne-Vaughn did not take the aggrieved person’s temperature and failed to document core maternal observations (blood pressure, heart rate, blood loss, fundus, temperature, and perineum condition). Another midwife assessed the secondary perineal tear as not requiring suturing, but RM Burne-Vaughn documented that the perineum was “intact”. Further, communication to the aggrieved person and her whānau was below the expected standard. RM Burne-Vaughn did not communicate key information about the baby’s condition, in particular that baby was stillborn, and completed the Medical Certificate of Cause of Fetal and Neonatal Death incorrectly. For four days post-birth the whānau were under the impression that their baby had been born alive and passed away during resuscitation. RM Burne Vaughn, as LMC, also failed to provide culturally appropriate care and emotional support to the aggrieved person.
RM Burne-Vaughn accepted that she failed to provide services to the aggrieved person with reasonable care and skill, that her inadequate documentation failed to comply with relevant professional standards, and that she failed to provide information that a reasonable consumer in the aggrieved person’s circumstances would expect to receive postnatally. The Tribunal considered the agreed summary of facts filed with the claim and issued a declaration that it was satisfied RM Burne-Vaughn had breached Rights 4(1), 4(2), and 6(1) of the Code of Health and Disability Services Consumer’s Rights.
A link to the Tribunal’s decision can be found at: