Human Rights Review Tribunal,  NZHRRT 38, (2 August 2019)
The Director of Proceedings filed proceedings by consent against the defendant midwife, Mrs N, in the Human Rights Review Tribunal (“the Tribunal”) regarding her care of a young, first-time mother, Cerise Lawn.
Mrs N, then a hospital midwife at Taranaki Base Hospital, took over care of Mrs Lawn at 11pm on 23 January 2012. At that stage Mrs Lawn had been in hospital for eleven hours, in established labour for ten hours, and in a birthing pool for four hours. Despite the presence of increasing maternal tachycardia (high pulse rate), meconium (fetal stool) in the amniotic fluid, an increasing fetal heart rate baseline, episodes of fetal tachycardia, and raised maternal temperature (pyrexia), Mrs N failed to take appropriate steps to monitor both mother and baby (including continuous electronic fetal monitoring), and failed to contact the lead maternity carer (LMC) obstetrician or, in his absence, the duty obstetrician, to notify them in a timely manner of Mrs Lawn’s clinical presentation. It was not until 2.37am on 24 January that Mrs N contacted the LMC, who arrived at 2.50am. When Mrs Lawn’s baby was born at 3.50am covered in meconium, pale and floppy, and in respiratory distress, Mrs N failed to call the neonatal unit when the LMC obstetrician did not. Mrs Lawn’s baby suffered hypoxic ischaemic encephalopathy with seizures, and was diagnosed with Group B Streptococcus sepsis (GBS) and resulting GBS meningitis. Her baby has experienced significant and complex health difficulties and developmental problems.
As a consequence of the actions and inactions of Mrs N, Mrs Lawn lost the benefit of receiving appropriate midwifery care and, in particular, the timely detection and appropriate treatment of maternal infection and fetal compromise; the benefit of earlier specialist intervention; the benefit of making informed decisions about her labour and delivery; and the benefit of receiving timely and appropriate resuscitation of her baby. As a result, Mrs Lawn has suffered significant and enduring emotional distress, grief and trauma, and injury to her feelings. Mrs N accepted that her failures in care amounted to a breach of the Code of Health and Disability Services Consumers’ Rights (the Code), and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that Mrs N failed to provide services to Mrs Lawn with reasonable care and skill, and issued a declaration that she breached Right 4(1) of the Code.
The Tribunal subsequently granted Mrs N a permanent order prohibiting publication of her name and identifying details.
The Tribunal’s full decision can be found at http://www.nzlii.org/nz/cases/NZHRRT/2019/38.html