Mum and baby deaths: Coroner slams midwife
A midwife working with a young Waikato woman had numerous opportunities to make decisions that could have given a mother and son a better chance of survival, a coroner has found.
Instead, the pair died within days of each other in May 2012 after a series of errors.
READ MORE: New midwives should not lead care - coroner
A coroner's court report from Garry Evans into the deaths of Huntly woman Casey Missy Turama Nathan, 20, and her baby son Kymani in 2012 says the lead maternity carer (LMC) failed to act at "intersectional points" because of inadequate training and experience.
She cannot be named because of a permanent suppression order.
Casey Nathan collapsed in a birthing pool before she delivered her baby at a Waikato birthing centre.
Kymani was in immediate need of resuscitation, and Casey was in a critical condition when she was taken to Waikato Hospital.
She died that afternoon.
Kymani was also taken to hospital, where he died two days later.
When giving evidence for the coroner's inquest, the LMC came across as "confident, capable, intelligent and articulate", the findings said. "If she had a fault it was an overweening confidence in her own ability."
But the outcome for mother and baby could have been different if simple actions had been taken during the pregnancy, counsel for the coroner's court Chris Gudsell said.
"A simple referral for a scan may have [made] the difference between the tragic deaths of both mother and baby and the successful labour and birth."
High fundal height measurements were made at three points during the pregnancy - the measurements are used to assess how the baby is growing and developing.
Midwives believed Kymani was big, when in fact he was small for his age, the coroner's report said. A scan would probably have picked up the "developmental anomaly" and the increase in fluid around the foetus that was associated with it.
The birth would then have been likely to be transferred to Waikato Hospital.
And giving birth at the centre "maximised [the mother's] chances of a bad outcome in circumstances that were identifiable antenatally", a report from obstetrician and gynaecologist Dr Sylvia Rosevear said.
Casey Nathan had risk factors, including her youth, irregular attendance of antenatal appointments, and that she was a smoker.
Expert witness midwife Jacqui Anderson said there were "a whole lot of building blocks" which could have been put together to make a different decision about where the birth took place.
Even during the labour there were red flags to bring in experts, the Coroner found. The labour progressed slowly and and expert consultation was mandatory by 6.59am, expert witnesses agreed.
Medical witness Dr Tony Baird, said Casey's chances of survival would have been about 80 per cent if she had been sent to Waikato Hospital about 7am or 8am on May 21. Yet the midwife noted at 6.46am that she was doing "brilliantly".
About 10.30am the mother collapsed and lost consciousness in the pool, and an ambulance was called.
In the coroner's findings, pathologist Dr Mark Smith of Christchurch called this a sentinel event "that initiated her catastrophic decline".
Casey appeared to improve after she was taken out of the pool and given oxygen but the baby's heart rate was described as "not reassuring".
The LMC should have been asking herself if the baby's abnormal heartbeat might be linked to the mother's collapse, the court said.
"The complications were too complex for the LMC's training, experience or the resources in the low risk birthing unit."
It was also unclear who was taking control and St John ambulance officers ultimately had to do so. Although ambulances were on standby, the mother was not sent to hospital as soon as she should have been.
The mother's death was due to multiple system failure from an amniotic fluid embolism – when amniotic fluid or foetal material gets into the mother's bloodstream.
The baby suffered a brain injury due to a lack of oxygen during labour and other complications.
The midwife who was lead maternity carer has moved overseas and is still practising.
The court heard she was "very well regarded" and had worked hard to re-establish her professional reputation.
She had met requirements for continuing professional development.
Casey Nathan's family are pleased with Coroner Garry Evans' long list of recommendations and have now lodged a complaint with the Health and Disabilities Commission.
Family spokesperson Jenn Hooper, of Aim (Action to Improve Maternity) said the family had taken comfort knowing what happened to 20-year-old Nathan and baby Kymani.
"The first thing the coroner's court did was give them answers on what happened. Families like this struggle all the time to find out what happened to their children.
"Now they know blow by blow what happened and that has given them an awful lot of answers. Sure, parts of it angered them and other parts of it gave them a bit of peace."
Hooper said there was never going to be a winner, but the strong recommendations in the coroner's report were the best they could have hoped for.
"I've explained to them that these are about the strongest recommendations anyone's ever seen. [It] is a strong recognition of the seriousness with which this case was dealt with by the coroner and the court and they are very grateful for that."
Although the release of the report marks the end of the coroner's inquest, Hooper said the family have now lodged a complaint with the Health and Disabilities Commission.
"They're very aware that nothing can bring your loved ones back... of course this isn't over. This is never over for them anyway. They were understanding that the coroners court was about the system. It was never going to be about the practitioners. That's not how it works."
She said the family are at varying stages of grief although the intensity they felt two-and-a-half years ago has softened.
"Forgiveness is such a personal thing and some people have it without realising it, and some people never get it and it doesn't mean you can judge that person. They'll never forget."
CORONER HITS BACK AT CRITICS
Coroner Garry Evans has hit back at critics of his findings into the death of a Waikato mother and baby, saying their widespread criticisms were not matched by helpful analysis.
Evans' comments came after his provisional findings were sent to the Midwifery Council of New Zealand and the New Zealand College of Midwives.
Evans slammed remarks made by Karen Guilliland from the New Zealand College of Midwives who accused the court of relying on ill-informed medical opinion.
Guilliland criticised the court's treatment of evidence, its findings and recommendations.
In reply, Evans said it was disappointing Guilliland's widespread criticisms were not matched by helpful analysis of the case or the standard of the midwife's training and education.
Evans said Guilliland's description of three senior obstetricians as "ill informed", all of whom gave evidence at the inquest, did a grave disservice to each of them and was unhelpful to the court.
Similarly, Evans said although the Midwifery Council of New Zealand criticised his findings, they did not provide an alternative explanation for the "errors of judgement and failures to follow proper midwifery practice that occurred in this case".
HOW IT UNFOLDED
Nov 3, 2011 11.5 weeks pregnant. First visit to midwife. Midwife fails to measure height or weight
May 18, 2012 39.6 weeks. Fundal height measured and, for third time, is on or exceeds 90th per centile. Urgent ultrascan should be ordered by midwife but is not. Mother uninformed of problem.
May 20, 1.20am Labour starts and mother enters birthing centre. Vital signs taken by midwife, but not recorded.
2.15am Mother first enters 37deg birth pool. Temperature of 35deg recommended for early stages of labour. Vital signs taken.
6.59am Less than 2cm of dilation in 5.5 hours suggests slowing of labour. Mother not consulted and specialist consultation not recommended.
9.38am Now fully dilated mother re-enters 37deg birthing pool. Vital signs not taken.
10.03am Mother begins to push. Foetus heart rate monitored every 10 minutes.
10.39am Mother collapses and drifts in and out of consciousness. She's given oxygen, removed from pool and ambulance called. Foetal heart rate "not reassuring".
10.56am Ambulance arrives and is put on standby.
11.02am Baby born pale and lifeless. Resuscitation commenced. Blood loss by mother estimated at 1000mls. Anything above 500mls considered a problem.
11.07am Baby seems to suffer a fit. Guidelines say neonatal resuscitation unit should be called.
12.20pm Mother's vital signs taken, the first time since 10.39am. Blood pressure and pulse "very worrying".
12.42pm Mother's blood pressure and pulse continue to fall. Call to Waikato Hospital specialist unit goes to answerphone. Eventually contact is made.
1pm Mother enters ambulance for transfer to Waikato Hospital. Both mother and baby arrive before 2pm.
3pm Mother suffers final cardiac arrest and shortly after dies. Baby dies on May 23.
- Waikato Times