By 1news.co.nz
A newborn infant was nearly killed by hypoglycaemia after an Auckland maternity hospital failed to identify the baby’s worsening condition, an investigation has found.
Deputy Health and Disability Commissioner Rose Wall found Birthcare Auckland Limited and a registered midwife were in breach of the “right every consumer has to services provided with reasonable care and skill”.
As a result of “the significant failings identified in this case”, Birthcare and a midwife have been referred to the Director of Proceedings to decide whether proceedings should be taken, Wall said.
The baby involved in the 2019 incident now has cerebral palsy with significant developmental delays. The specific dates involved were redacted for privacy reasons.
“The baby’s hypoglycaemia and corresponding deterioration culminated in him collapsing during an ambulance transfer to the neonatal intensive care unit at the public hospital,” Wall’s report read.
“During the ambulance ride, the baby had a seizure, and his heart stopped, and he required resuscitation. In hospital, scans showed the baby had extensive brain damage, and he was not expected to survive.
“However, the baby’s condition stabilised and, at time of writing, is reported to be well, although he has cerebral palsy with significant developmental delays.
“The family faces ongoing uncertainty around the extent of the impact of the baby’s brain damage on his future development.
“There were also serious shortcomings in Birthcare’s subsequent management of the adverse event and in their response to the parents’ complaint.”
Wall warned that basic omissions in the care provided to an otherwise healthy infant could have extremely serious consequences.
“The registered midwife did not follow the correct basic life support protocols required in an emergency situation such as this. The infant was in respiratory and cardiac arrest. Chest compressions should have been initiated promptly,” Wall said.
The infant was born healthy at Birthcare, but in the 24 to 48 hours following his birth, his health declined as he developed hypoglycaemia (low levels of sugar in the blood).
“A delay in identifying and treating the hypoglycaemia resulted in the infant going into respiratory and cardiac arrest, requiring resuscitation during an ambulance transfer to the public hospital’s neonatal intensive care unit.
“Several Birthcare midwives demonstrated shortcomings in the provision of care. However, the midwife caring for the infant over the critical period should have recognised and responded appropriately to the troubling clinical picture as it was emerging.”
The midwife demonstrated inadequate independent clinical decision-making at key points, according to Wall’s report.
“Careful consideration of all of the infant’s symptoms should have alerted the midwife to the seriousness of the situation and led her to investigate further by way of a full assessment and then intervention. This did not occur.
“The midwife was found to have not appropriately managed the infant’s hypoglycaemia, or taken appropriate actions in recording vital signs prior to the ambulance transfer or administering oxygen during the ambulance transfer.”
In the context of treating hypoglycaemia, Wall said the maternity hospital’s policy on neonatal hypoglycaemia was not consistently well understood by staff.
“While hypoglycaemia and its management are within a midwife’s scope of practice, it is incumbent on providers, like Birthcare, to ensure its staff are aware of the particular requirements of its own policies to maintain a consistent standard of care, Wall said.
She said there was a fundamental failure to deliver services to a vulnerable infant with care and skill because nobody at Birthcare administered the infant dextrose gel when he was hypoglycaemic.
Wall found Birthcare breached Right 10 of the Health and Disability Services Consumers’ Code for their poor handling and management of the adverse event and the parents’ subsequent complaint.
“Right 10 gives consumers the right to complain about a provider in any form appropriate to them and the provider must facilitate a fair, simple, speedy and efficient resolution of complaints.”
Additionally, she found Birthcare in breach of the code for failing to communicate openly, honestly and effectively with the parents about the complaint, and for failing to openly disclose that the adverse event was being reviewed.
Wall made a number of recommendations, including:
- That Birthcare and the midwife provide written apologies to the infant and his parents for the deficiencies identified in the report.
- That two of the midwives involved in the adverse event and complaint management each provide a personal letter of apology to the parents for their unprofessional communications, and that current Birthcare senior staff upskill in complaint management.
- That Birthcare provide HDC with evidence of staff training in documentation of handover and escalation, emergency skills, and roles and responsibilities during ambulance transfers.
- That Birthcare update its Reportable Events Policy to include consumer participation as a key principle, and implement this as a meaningful part of its reportable events process.
