An internal investigation has confirmed a heavily pregnant woman aged in her 20s and her stillborn fetus died after the mother's admission to Palmerston North Hospital's intensive care unit was delayed.
The incident happened in February 2022 and was revealed by RNZ later that year, prompting then-prime minister Jacinda Ardern to call it a "devastating story".
The woman, whose name is suppressed by an order from the coroner, arrived at hospital in the early hours of the morning with signs of severe sepsis, but was not admitted to the unit until the early evening despite it being clear to staff she was likely critically ill. She died later that night.
Until now Te Whatu Ora Health New Zealand has declined to discuss the circumstances or the woman's death or release its internal serious adverse event report, completed in April 2023.
But after a further request from RNZ it has released a summary of the report, which includes two findings.
One is: "Multiple delay in the diagnosis of sepsis, identification of source of infection and treatment".
The other is "multiple gaps in documentation", including in recordings of observations and a medical emergency team call. Further bullet points under this finding allude to gaps in communication, cultural responsiveness and cardiotocography - which measures a baby's heart rate and contractions in the womb.
Five recommendations are listed.
They are to review the "escalation pathway" for women in the birthing suite whose condition is deteriorating; provide refresher training on structured communication; make sure staff document maternal observations in the appropriate place; and make sure staff understand and are familiar with local fetal surveillance guidelines.
Reviewing the processes for perimortal caesarean - the surgical delivery of a baby during or near the mother's death - and making sure surgical equipment is available promptly are also recommended.
Under the heading "follow up", the summary said: "A number of recommendations have been completed around training for staff and updating of procedures."
The summary does not mention staff culture, but RNZ understands that at the time of the incident there were concerns about intimidation and bullying in the intensive care unit.
And a report commissioned after the February 2022 incident found many doctors at Palmerston North Hospital operated under a siege mentality, where they feared speaking out about concerns, and they often faced barriers when trying to transfer patients between departments.
This week RNZ asked Health NZ further questions resulting from the summary, including how the delays in admission to the unit happened.
A statement from MidCentral group director of operations Sarah Fenwick said the death of the woman and her child was "a tragic event and our thoughts are with her whānau".
"As this case is still active before a coroner, we are unable to comment on the specific treatment this woman received."
RNZ also asked which of the report's recommendations had been implemented.
Fenwick's statement repeated the report summary, saying: "A number of recommendations have been completed around training for staff and updating of procedures."
Sepsis is considered a preventable cause of maternal death, but Society of Obstetric Medicine of Australia and New Zealand guidelines say prompt treatment is essential.
It is usually caused by a bacterial infection. When the body fights this it leads to damage to tissues and organs.
The completion of the internal report in April 2023 meant it took more than a year, well outside the 70 working-day period then set by the Health Quality and Safety Commission.
When Ardern was asked about the incident at a post-cabinet press conference in 2022, she described it as devastating and said: "It's really important we understand what has happened here."
The Health and Disability Commissioner and Coroner Meenal Duggal are also investigating.
Unit refurbishment delayed
After the 2022 incident, RNZ reported that the Palmerston North Hospital intensive care unit was considered outdated as far back as 2012, when a review found it had "severely compromised" working space.
Health NZ said in late 2022 that a refurbished eight-bed intensive care-high-dependency unit was expected to be fully staffed by mid-2023.
This week Fenwick said the refurbishment "has not yet progressed".
"However, funding to develop a suitable solution has been included in our capital planning process. ICU has seven fully resourced beds and can flex to eight if required.
"Additional funding was also secured to create a critical care educator role, which provides support for a patient-at-risk service 24-7 for the hospital and allows nurses to undertake post-graduate study."
There is still no date for when a replacement acute services block at the hospital, which includes the unit, will be built.
"The new acute services block is currently in the early planning stage as part of the regional hospital redevelopment programme," Fenwick said.
RNZ
