Director of Proceedings v Ms Tracey Goff

Health Practitioners Disciplinary Tribunal, 890/Mid16/373D,  (30 May 2017)

The Director of Proceedings filed a charge against midwife Ms Goff in the Health Practitioners Disciplinary Tribunal (“the Tribunal”) concerning her failure to respond to her client’s (Ms S’s) symptoms of pre-eclampsia and to follow core midwifery guidelines.

At her final antenatal appointment, Ms S’s blood pressure was taken and recorded as 140/100mmHg, which is high and was a significant increase from her booking blood pressure of 110/60mmHg. Ms S also reported having experienced headaches and black dots in her vision two weeks previously, and again on one occasion in the two days preceding the appointment. Ms Goff discussed the symptoms of pre-eclampsia with Ms S and advised her to make contact immediately if she experienced such symptoms. Ms Goff did not recommend to Ms S, or discuss with her at all, that she consult with a specialist in light of her high blood pressure.  Such a recommendation was required as per the Ministry of Health 2012 Guidelines for Consultation with Obstetric and Related Medical Services (the Referral Guidelines). In addition, Ms Goff failed to take any steps to assess Ms S for pre-eclampsia, such as arranging for blood tests and further urinalysis or making an appointment to re-check Ms S’s blood pressure.

The next morning, Ms S sent a text message to Ms Goff advising her that she had been experiencing headaches and spots in her eyes. Despite Ms Goff using her cellphone during the time that Ms S’s text message was sent and received, Ms Goff did not respond to Ms S’s text message until later that afternoon, and, when Ms Goff did respond, she failed to arrange (urgently or otherwise) to assess Ms S for pre-eclampsia in light of the symptoms Ms S had disclosed in her text message.

Ms S went into labour later that evening and arrived at the hospital at approximately 11pm. On admission, her blood pressure was taken and recorded as 167/97mmHg.  Ms Goff advised Ms S that her blood pressure was high, and that probably this was because she was in labour and tired. Ms Goff did not ask Ms S whether she was experiencing any other symptoms of pre-eclampsia, and did not carry out any further assessments in response to Ms S’s high blood pressure, such as asking Ms S to undergo blood testing or to provide a urine sample for testing. Ms Goff did not recommend to Ms S, or discuss with her at all, that she consult with a specialist, as required by the Referral Guidelines.

Ms Goff did not re-check Ms S’s blood pressure for almost two hours. At 1.05am, Ms S was found to be pale, and she reported feeling faint. Her blood pressure was taken electronically and recorded as 188/106mmHg. It was then taken manually and was recorded as 170/108mmHg. Ms Goff sent a midwifery student to consult with medical staff, rather than utilising the in-room emergency call bell or calling the 777 emergency phone line, which would have summoned immediate attention. The obstetric registrar who attended Ms S was immediately concerned, as Ms S was shaky, pale, reported feeling faint and nauseous, and had hyper-reflexia, clonus and a sense of impending doom, all concerning features that indicated impending eclampsia (seizure). Ms S’s condition was considered an obstetric emergency, and subsequently she was managed for severe pre-eclampsia. Ms S’s baby was delivered safely at 2.58am, and subsequently she remained in hospital for on-going treatment over six days.

The charge before the Tribunal proceeded by way of an agreed summary of facts whereby Ms Goff accepted that her cumulative failures to comply with the Referral Guidelines and to assess her client adequately for pre-eclampsia amounted to professional misconduct as per s 100(1)(a) or (b) of the Health Practitioners Competence Assurance Act 2003 (“the Act”). At the hearing, Ms Goff further acknowledged that she did not have an adequate understanding of pre-eclampsia.

The Tribunal accepted that Ms Goff’s conduct amounted to professional misconduct (as malpractice, negligence, and conduct bringing discredit to the profession) and noted that symptoms of pre-eclampsia call for prompt and urgent action. The Tribunal further accepted that there were multiple opportunities for Ms Goff to correct her initial error of not screening her client appropriately or recommending a consultation with a specialist, and that it was particularly concerning that Ms Goff’s failure to respond to her client’s worsening symptoms occurred three times over a 48-hour period.

In considering penalty, the Tribunal stated that this may have been a case that called for suspension of Ms Goff’s registration, had that not occurred already, subsequent to the Midwifery Council’s review of Ms Goff’s competence (ordered as a consequence of these events). Ultimately the Tribunal imposed multiple conditions on Ms Goff’s practice (should she succeed in having her suspension lifted), including supervision for no less than 18 months. Additionally, Ms Goff was censured and ordered to pay $9,000 towards the costs associated with the proceedings.

Ms Goff was declined an order for permanent name suppression on the basis that the private interests advanced by Ms Goff in support of her application were outweighed by the other public interest factors, including openness and transparency of disciplinary proceedings. A permanent order for suppression of the name and identifying details of Ms S had been made prior to the hearing.

The Tribunal’s decision can be found at:


Last reviewed February 2019