Doctor says sorry over newborn's death

17:49, Feb 27 2012

A doctor has apologised for an "error in judgment" that he says resulted in the death of a newborn girl.

A decision released yesterday by Health and Disability Commissioner Anthony Hill found the doctor and a hospital midwife – known only as Dr E and Ms D – failed to provide care of an appropriate standard to the mother and daughter.

The decision does not disclose at which district health board or hospital the incident took place.

In 2008, a woman – referred to as Mrs A in the decision – was pregnant with her first child. A scan at 37 weeks revealed the baby was large and health professionals recommended delivery at a public hospital. After going into labour the woman travelled to hospital, arriving at 2am. About 7am, the baby's head was delivered but the rest of the delivery was obstructed by shoulder dystocia.

In shoulder dystocia a baby's shoulder becomes lodged in the mother's birthing canal and the chest can be compressed, making it difficult for them to breathe. Baby A was born floppy and not breathing. She died the next day.

In 2009, her parents lodged a complaint with the commissioner about the services provided by three midwives and Dr E.


In January 2010, Dr E told the commissioner that after re-examining his notes and the CTG tracing, he realised that different actions on his part could have prevented the tragic outcome.

Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy – an abnormal reading can help identify signs of fetal distress.

The commissioner found that the registrar had breached the commission's code of rights because he misread the CTG trace and failed to take appropriate clinical action. In addition, he had failed to follow the relevant policies on CTG recordings.

In May 2010, Dr E provided a written apology to the baby's parents.

The midwife was also found to have breached the code when she recognised there was a problem and did not do everything she could to advocate for appropriate intervention, including escalating her concerns to the on-call consultant.

The commissioner found the DHB had met its duty of care to Mrs A.

"However, I do consider that the professional hierarchy in the DHB may have inhibited good teamwork and thus affected patient welfare."

The Dominion Post