The Taranaki District Health Board (DHB) has apologised after a Health Disability Commissioner report found it failed to provide an appropriate standard of care for a pregnant woman with diabetes that resulted in a miscarriage.
Deputy Commissioner Rose Wall released a new report on Monday that found Taranaki DHB (now Te Whatu Ora Taranaki) had breached the Code of Health and Disability Services Consumer’s Rights (the Code) for failing to provide an appropriate standard of care to a pregnant woman with diabetes.
The woman, who was in her twenties at the time, had several existing conditions, including type 1 diabetes.
The care provided by Te Whatu Ora Taranaki did not support her in adequately managing her diabetes throughout her pregnancy.
She miscarried at eight months but the report didn't identify any concerns with the midwifery and obstetrics care provided to the woman.
Wall said her role is not to determine what caused the baby's death but to decide whether the care provided was reasonable in the circumstances and consistent with the accepted standard of care.
The report focused on the Taranaki DHB endocrinology service’s management of the woman’s diabetes during her pregnancy.
At the time, Taranaki DHB did not have an established antenatal diabetes multidisciplinary team (MDT), which enables input from a diabetes midwife, an obstetrician, an endocrinologist, a diabetes clinical nurse specialist and a dietitian.
As a result, the obstetrics and diabetes teams were providing care to the woman from separate clinics.
Wall said this resulted in a clear disconnect between the two specialties and did not enable effective coordination of clinical care.
She found that Te Whatu Ora Taranaki failed to provide the woman with an appropriate standard of care in four ways.
- She was not seen for an initial consultation with the diabetes service in a timely manner, due to an administrative error.
- A dietician review was not arranged in a timely manner, owing to the referral not being marked as ‘urgent’ for the medical typists.
- A clinical nurse specialist review was not undertaken regularly, resulting in the woman being seen by the diabetes clinical nurse specialist on only four occasions throughout her pregnancy.
- Care between the diabetes and antenatal services was not coordinated effectively.
"I consider that the failings in this case indicate systems issues… In my view, the failure to coordinate the woman’s care effectively resulted in her not receiving services of an appropriate standard throughout her pregnancy," Wall said.
She said the Taranaki DHB breached Right 4(1) of the Code, which states every person has the right to services provided with reasonable care and skill.
The DHB also breached Right 4(5), which states every person has the right to cooperate among providers to ensure quality and continuity of services.
The Taranaki DHB conducted an external review of the care provided to the woman and has told the HDC it has made a number of changes as a result of the complaint.
The changes include the creation of a multidisciplinary team (MDT) that has been set up to coordinate the care of women with diabetes during pregnancy.
The team includes a consultant obstetrician, a consultant endocrinologist, a diabetes nurse specialist and an antenatal clinic coordinator.
The dietitian department has started recruiting two full-time dietitians who focus solely on diabetes. On top of that, two further people have been employed specifically to support Māori patients with the diabetes service (Kaitautoko).
After the changes, Wall recommended the Taranaki DHB write an apology to the woman and provide an update on whether recommendations in the internal review have been implemented.
She also recommended the DHB provide the results of an audit that was conducted and whether the changes have been implemented to address any concerns raised by the audit.
The final recommendation is to use this as a case study for the maternity/diabetes service multidisciplinary team to highlight the importance of careful planning and management of women with diabetes during pregnancy.
