Human Rights Review Tribunal, HRRT 040/2013,  NZHRRT 40 (14 November 2013)
On 1 May 2013, the Director of Proceedings filed a statement of claim against Ms Ester Maree Candish, registered midwife of Palmerston North. The claim was able to proceed by agreement and compensation for the consumer (Ms A) was resolved between the parties by negotiated agreement.
Ms A was pregnant with her first child, due in April 2011. Ms A's pregnancy had progressed normally, however, at approximately 39 weeks' gestation Ms A became concerned about a lack of fetal movement and increased vaginal discharge with black spots. She texted Ms Candish a message indicating those concerns. As Ms Candish had recently taken over Ms A's care, this text message was the first contact she had had with Ms A.
Ms Candish responded to Ms A's text message with advice that she should drink ice cold water and sit quietly on the couch to feel the baby move. A day later Ms Candish met with Ms A at the midwifery clinic. Ms Candish attempted to measure the fetal heart rate and had some difficulty, but recorded in the clinical notes that she eventually heard it.
At about 3am the following day Ms A began experiencing contractions. Ms Candish, accompanied by a student midwife, visited Ms A at 2.20pm that afternoon, by which time Ms A was in established labour. At that point Ms Candish attempted to measure the fetal heart rate. Ms Candish and the student midwife accompanying her had difficulty finding the fetal heart rate but once again Ms Candish recorded that she eventually heard it. Ms Candish and the student midwife left Ms A and returned later that evening when Ms A was fully dilated and in active labour. Once again the fetal heart rate was measured but Ms Candish recorded that it was difficult to find due to contraction.
Ms Candish found that Ms A was close to birthing her baby and therefore made plans to travel to hospital. Ms A and her mother travelled to hospital in a separate car to Ms Candish, however they became lost along the way and did not arrive at the delivery suite until approximately 20 minutes after leaving home. Ms A gave birth five minutes after arriving at the delivery suite. Unfortunately Ms A gave birth to a stillborn baby.
The Tribunal found that Ms Candish breached Right 4(1) and 4(2) of the Code by failing to provide services to Ms A with reasonable care and skill and failing to comply with legal professional ethical and other relevant standards. In particular Ms Candish's use of text messaging to respond to Ms A's concerns about reduced fetal movement was not appropriate. Ms Candish failed to follow up her text message to ensure Ms A had felt fetal movement. Also, given that it is extremely unusual for a midwife to have difficulty detecting the fetal heart rate in full-term pregnancy, Ms Candish should have checked the maternal pulse and arranged for a cardiotocograph (CTG) when she had difficulty detecting the fetal heart rate. Ms Candish should not have left Ms A for approximately five hours when Ms A was in established labour, and in circumstances when Ms Candish should have remained in order to monitor the baby's and mother's wellbeing. Ms Candish should also not have left Ms A without midwifery support for the short drive to the hospital, given that Ms A was in advanced labour.
The Tribunal's decision can be found at http://www.nzlii.org/nz/cases/NZHRRT/2013/40.html
Last reviewed February 2019