A pregnant woman who lost her baby after 33 weeks' gestation was failed by her obstetrician and gynaecologist, the Deputy Health and Disability Commissioner has found.
The woman, referred to as Ms A in the Commissioner's report released on Monday, underwent multiple assessments at her public hospital's maternity service in 2021.
At 33 weeks pregnant, Ms A's waters broke - she was experiencing ongoing clear vaginal discharge and given ongoing antibiotics, pain relief and steroids. At that stage, her discharge did not indicate infection.
She was admitted to hospital but discharged a few days later.
The following week at a pre-scheduled appointment, Ms A was seen in the maternity clinic as she had developed green vaginal discharge and was experiencing abdominal pain.
An induction of labour at 37 weeks' gestation was then arranged for the woman, before she was discharged home. She was advised to return to hospital if she had concerns.
But the next day she went to hospital experiencing labour contractions - it was there a foetal heartbeat could not be heard during a scan and the soon-to-be first-time mum sadly found out her baby was stillborn.
The woman delivered her baby vaginally and had the placenta removed surgically.
Following the traumatic experience, Ms A's mother raised concerns with the Health and Disability Commissioner.
In the Commissioner's findings out Monday, it was found Ms A's obstetrician and gynaecologist breached the Code of Health and Disability Services Consumers' Rights in his care of Ms A who was discharged home despite her showing "red flag" symptoms for infection and experiencing abdominal pain.
"Given the presence of green discharge and Ms A's ongoing abdominal pain, I am critical that Ms A was discharged home without any further assessment," Deputy Health and Disability Commissioner Rose Wall said in a statement upon releasing the findings.
"Chorioamnionitis can present subtly and develop rapidly. This would have placed the wellbeing of her foetus at risk. For this reason, I would have expected [the gynaecologist] to arrange for Ms A to be admitted to the maternity unit for full investigations to be undertaken. This did not occur."
Wall said the gynaecologist, referred to in the report as Dr C, failed to provide services to the woman with reasonable care and skill because he did not investigate the concerning green vaginal discharge appropriately.
Wall also agreed with independent expert advice provided for the report which said the decision to discharge the woman was a severe departure from accepted practice.
Dr C has accepted the woman should have been admitted to the maternity unit for further assessment.
Dr C added that despite frequent reflection on the events, his rationale for the decision to discharge Ms A home is unclear.
"I still cannot think of any human factors that might be relevant as, although they would not have excused my mistake, they might have explained why it occurred. Their absence is a concern to me, as I really would like to understand why I made such a basic mistake," he's quoted in the report.
"I cannot reverse it (unfortunately) but would like to have better confidence that I wouldn't make such a mistake again. Even the concern expressed by the sonographer over the lack of liquor… should not have distracted me from the significance of the green liquor."
Ms A and her family had a meeting with Health NZ representatives, including Dr C and the Clinical Midwifery Manager, to discuss the family's concerns and the events leading up to the death.
Dr C admitted he'd made a mistake and sincerely apologised. He also said he had done further reading on the management of preterm premature rupture of membranes (PPROM).
Following the incident, Health New Zealand Te Whatu Ora undertook a review and found that there were variations in the PPROM guidelines throughout New Zealand.
Health NZ has since developed a pamphlet on self-monitoring for women at home who have confirmed pre-term rupture of membranes.
"We accept all of Dr [Judy] Ormandy's [who provided independent advice on the case] findings and wish to again apologise to [Ms A] and her whānau for the sad loss of [her unborn baby]," Health NZ said in response.
Wall also recommended Health New Zealand update its obstetric orientation to stress the importance of assessing patients who show symptoms of infection and provide HDC with updates that came out of its serious events analysis.
