A newborn baby died after a District Health Board, a self-employed midwife, and a paediatric registrar provided below-par care to the mother during birth and child afterwards.
Deputy Health and Disability Commissioner Rose Wall found the Code of Rights were breached in caring for the woman and her child, who spontaneously went into labour in 2016. No-one, including the DHB, is named in the case.
Wall said after several hours of labour, the mother was mistakenly assessed as having progressed to the second stage with some signs of fetal distress.
Following that, the labour continued but further signs of fetal distress were not reported to the obstetrician.
Eventually, the baby was delivered by caesarean section and required resuscitation.
The following day, the baby died after becoming "very unwell" and requiring intensive care. Wall said the care was "sub-optimal" and included a "significant drug error" - where the paediatric registrar administered an incorrect dose of midazolam to the baby.
"The Deputy Commissioner found a number of omissions in the woman's care after her Lead Maternity Carer (LMC) rang the emergency bell when she noted meconium in the liquor following a spontaneous rupture of membranes," the Health and Disability Commissioner report says. "The Deputy Commissioner considered that the LMC's lack of clarity regarding her ongoing role and responsibility and the handover to secondary care contributed to the omissions," the report says.
Wall found the health board's care was also "inadequate" in places and recommended it develop guidelines that set out the transfer process from primary to secondary maternity care at the hospital.
"The Deputy Commissioner was also critical of aspects of the care provided by the hospital midwife who assisted with the labour," the report says
A report was also commissioned by the DHB after the event. It told the commissioner that the inadequate monitoring of fetal wellbeing resulted in an incorrect assessment of fetal distress.
"I would like to pass on our sincere condolences on the death and loss of [the baby] and apologise unreservedly for the inadequate care," the health board's chief executive said in the report.
Wall said the midwife also undertook several actions to meet the requirements of the Midwifery Council competence programme.
