Baby's death could not be expected

23:09, Jul 18 2014

A Manawatu mum is disappointed she did not insist on telling her story to a coroner after the death of her newborn baby at Palmerston North Hospital just over a year ago.

Linden Nepia said she felt let down by the report and wished she'd talked to coroner Chris Devonport.

The coroner decided an inquest was unnecessary.

Jayzarn Tu Kaha Robert Simeon was born full-term in July last year, and was a healthy weight and apparently doing well a few minutes after delivery - "everything had gone well from a midwifery point of view", Devonport said.

But within half an hour, he was barely responding to a Vitamin K injection and was pale all over. Within an hour, he was barely gasping and had a slow heart beat.

After two hours of resuscitation efforts, he had signs of severe brain damage. Attempts to revive him stopped, and he died.


Devonport made no formal criticism of independent midwife Julie Robb-O'Connell or anyone else involved in Jayzarn's care.

He found that hours or days before birth, the baby had discharged meconium, which he then inhaled.

Some remained in his lungs and, after delivery, it triggered bleeding that affected his lungs.

Devonport said the problem could not have been anticipated, and there was nothing he could recommend that would be likely to prevent other babies dying in such circumstances.

He did comment, however, that it was unfortunate the midwife had not taken part in the hospital's post-event review.

New Zealand College of Midwives chief executive Karen Guilliland defended the right to abstain. After the death the midwife became aware of rumours about her safety as a midwife, and took leave over the stress.

The coroner's finding proved the prejudgment was "erroneous, if not defamatory", said Guilliland.

The college expected midwives to take part in post-event reviews, but also defended their right to natural justice.

As they were not health board employees, independent midwives were not covered by the same employment and insurance protection as staff.

Devonport also questioned whether it would have made a difference if a second midwife had been present to spot the baby's deteriorating condition, but Guilliland said it was not usual to have two midwives in the room after a normal birth.

He also queried whether the emergency call button was easy enough to access.

Nepia said she was still considering making a formal complaint. She said the night she started labour she had sent several messages to Robb-O'Connell, who did not respond, so she went to the emergency department.

She said the midwife seemed "drained and tired", and she thought she was slow to get help.

MidCentral Health Operations Director for Specialist Community and Regional Services Nicholas Glubb said the coroner's comments would be carefully considered.

Contractual arrangements with midwives could not force them to take part in reviews.

Manawatu Standard