Director of Proceedings v Campbell

Human Rights Review Tribunal, [2015] NZHRRT 10 (9 April 2015)

A declaration was made by consent between the parties that Ms Campbell (née Rowan) breached Rights 4(1) of the Code of Health and Disability Services Consumers' Rights by failing to provide midwifery services to Mrs Barlow with reasonable care and skill, and Right 4(2) by failing to provide services that complied with legal, professional, ethical, and other relevant standards.  The matter (including issues of compensation) was able to proceed by way of negotiated agreement. 

Mrs Barlow was a second time mother who had experienced difficulties during her first labour.  At 37 weeks' gestation she chose Ms Campbell as her LMC after her first chosen LMC commenced long-term sick leave.  Unbeknown to Mrs Barlow, Ms Campbell was a newly graduated midwife.  Ms Campbell briefly touched on Mrs Barlow's previous delivery and the current birth plan, but not in depth.  Three days beyond her due date, Mrs Barlow was concerned that she was going to have another difficult labour because the baby was posterior, like her first son.  At 12.30am on 25 October 2009, five days past her due date, Mrs Barlow's waters broke spontaneously at home and contractions started.  At 4am at the birthing clinic Ms Campbell assessed Mrs Barlow as being in early labour and recommended that she return home.  Ms Campbell accepts that her assessment of Mrs Barlow was incomplete and not thorough.  Mrs Barlow was experiencing significant pain and asked to remain at the clinic so she could manage her pain using the birthing pool and continuing to use Entonox. 

Ms Campbell recommended pethidine for pain relief, which was administered to Mrs Barlow at 5.15am.  Ms Campbell did not assess Mrs Barlow's vital signs or the fetal heart rate prior to or after the administration of pethidine.  Ms Campbell accepts that she failed to adhere to the clinic's pethidine policy and that she should not have sent the Barlows home, especially after pethidine administration.

At 6am the Barlows were sent home when it was not clinically appropriate to do so and against their wishes.  Ms Campbell did not examine Mrs Barlow prior to discharge.  The Barlows arrived home at 6.30am.  Mrs Barlow was still experiencing strong, regular contractions and in pain despite the pethidine.  

At 9.30am Mr Barlow called Ms Campbell to come to their home, as they were scared, anxious, and exhausted.  Ms Campbell arrived at their house at 10am and assessed Mrs Barlow.  Mrs Barlow was fully dilated, her contractions were strong with three to four contractions every ten minutes and lasting 60 seconds, and Mrs Barlow was pushing involuntarily at the height of her contractions.  Ms Campbell instructed Mrs Barlow not to push.  Ms Campbell called a priority one ambulance at 10.22am and Mrs Barlow was transported to the clinic.  Ms Campbell accepts that she did not consult the Barlows about whether they wished to go to hospital at that point or back to the clinic, and that she should have done so.  Ms Campbell also accepts that Mrs Barlow should have been transferred from home to hospital.

Mrs Barlow arrived at the clinic at 11am and commenced active pushing.  Ms Campbell failed to monitor the fetal heart rate adequately at the clinic between 11am and 12.45pm and did not take any maternal observations other than Mrs Barlow's temperature at 12.15pm.  At 12.30pm, because of her failure to progress, Mrs Barlow was transferred to the local hospital by ambulance.  Ms Campbell accepts she failed to consult a specialist and/or transfer Mrs Barlow to secondary care in a timely manner.  Ms Campbell also accepts it was her responsibility to ensure formal handover of Mrs Barlow's care to secondary services on arrival and that she failed to clarify who was responsible for Mrs Barlow's ongoing care at Hospital.  Ms Campbell also failed to provide adequate handover information about Mrs Barlow's history and labour to Hospital staff.  Mrs Barlow was assessed at hospital by a registrar at 1.20pm, who instructed Ms Campbell to take Mrs Barlow's observations, insert an intravenous (IV) luer and commence IV resuscitation for Mrs Barlow, and to monitor the fetal heart rate and call her if there were any concerns. 

Ms Campbell failed to monitor both Mrs Barlow's condition and the fetal heart rate adequately at Hospital.  She also failed to adequately document her assessments and care of Mrs Barlow and the fetal heart rate.  Ms Campbell accepts she failed to identify that the fetal heart rate was abnormal until she called the registrar back to assess Mrs Barlow at 2.25pm.  At 2.30pm Mrs Barlow was pale, tachypnoeic, complaining of difficulty breathing, and had a distended abdomen and abnormal mottling of the skin.  At 2.40pm it was decided to proceed with an emergency Caesarean section for possible uterine abruption.  Baby Adam Barlow was delivered at 3pm by emergency Caesarean section but could not be resuscitated and, sadly, died shortly after birth.  Mrs Barlow suffered a spontaneous uterine rupture, which led to a major intra-abdominal haemorrhage, which caused her to collapse.  She required an emergency total abdominal hysterectomy under general anaesthetic, with simultaneous resuscitation and blood transfusions during the procedure.  Mrs Barlow had a complicated postoperative recovery, with an initial inpatient stay of 37 days.  

The Tribunal's full decision can be found at https://www.justice.govt.nz/assets/2015-NZHRRT-10-Director-of-Proceedings-v-Campbell-Combined.pdf