A woman's baby died inside her after staff at Waikato Hospital failed to properly manage her hypertension during pregnancy.
In a release on Monday, Deputy Health and Disability Commissioner Rose Wall found Waikato District Health Board, now Te Whatu Ora Waikato, in breach of the Code for not providing the woman with reasonable care.
The woman, who was pregnant with twins, visited the emergency department when she was 12 weeks along because she was experiencing headaches and nausea. She required acute management of early-onset hypertension.
But Deputy Commissioner Wall said no effective plan was put in place to monitor her pregnancy and the woman was later admitted to hospital with intrauterine growth restriction, as one of the twins had an abnormal heart rate.
It was then confirmed only one foetal heartbeat was present and the woman was told one of her babies had died in utero. On the same day, her babies were delivered by emergency caesarean section.
Attempts to revive one of her babies were unsuccessful but the other was born healthy. The woman said when she was told her baby was dead she advised staff she needed whānau to care for them while she was unable to.
Deputy Commissioner Wall found the woman's whānau were not told, nor was a cultural support person brought in to be with the woman (who is Māori) while she worked through the immediate aftermath of losing her baby.
Wall found Waikato DHB breached Right 4(1) of the Code, which gives consumers the right to have services provided with reasonable care and skill.
She said she accepted the circumstances were challenging, but the cumulative deficiencies in the care provided amounted to the breach.
The deputy commissioner also criticised Waikato DHB’s care after the woman first presented to the emergency department, specifically the lack of a plan to monitor the woman's condition.
Wall was also critical that medical input was not sought when two separate heartbeats could not be identified clearly, and of the decision over whether to deliver the babies early.
Wall recommended Te Whatu Ora Waikato provide a written apology, train staff on the management and monitoring of hypertension and pre-eclampsia in twin pregnancies, and provide HDC with a copy of its cultural/kaupapa training framework, outlining how the practice of tikanga with patients and their whānau is developed with all hospital staff.
