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Auckland, December 14, 2020
Deputy Health and Disability Commissioner Rose Wall has released a report finding Waikato District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights for the care provided to a pregnant woman.
The woman, who was 28 weeks pregnant, presented to the public hospital with abdominal pain.
Assessments by the obstetric and general surgical teams had not established a cause for the pain before the woman collapsed 17 hours later and was found to have a ruptured uterus.
The baby initially survived but died a month later as a result of birth hypoxia.
Ms Wall noted that the rupture of an unscarred uterus in a non-labouring woman is extremely rare and, prior to the woman’s collapse, it was not a diagnosis that would have been considered or made by many clinicians in the circumstances.
Deficiencies noted
However, the Deputy Commissioner criticised Waikato DHB for a number of deficiencies in the Obstetric and General Surgery reviews. These included missed opportunities for increased senior oversight and inadequate documentation of some reviews.
Ms Wall also considered that a lack of effective communication and coordination between the Obstetrics and General Surgery teams contributed to a delay in appropriate radiological assessment.
Recommendations for action
Ms Wall recommended that Waikato DHB report on the action points identified in its Serious Incident Review Report; provide evidence of recent staff training on coordination of care, escalation of care, and documentation; use the report as a basis for staff training; and report back on its implementation of the New Zealand National Maternity Early Warning System (MEWS).
She also recommended that the DHB apologise to the woman and her family and acknowledges compliance of the recommendations.
Source: Health and Disability Commissioner, Wellington
