Hospital, midwife criticised over baby's death

04:23, Feb 05 2014

A damning report by the Health and Disability Commissioner has slated Waikato Hospital staff and a midwife at the centre of a botched birth in 2009, in which the baby died soon after being born.

Commissioner Anthony Hill released a report today, which found midwife Jennifer Rowan - who now goes by the name of Jennifer Campbell - to be in breach of the Code of Patient Rights. She had made "severe departures from the accepted standard of care" while dealing with Linda Barlow, who was in labour with her son, Adam, on October 25, 2009.

A coroner's report released a year ago found Adam died as a result of intrapartum asphyxia - a lack of oxygen to the brain and vital tissues during labour - and today's report by the commissioner gives further details of his disastrous start to life.

The newly graduated midwife had assessed Barlow at a birthing centre at 4am after her waters broke and contractions started several hours earlier.

Hill said it was known to the midwife that the baby was in the posterior position. Barlow had experienced difficulties with the birth of her first son, and was anxious and in pain.

Hill found that over the following 10-1/2 hours, Campbell did not adequately assess and monitor Barlow and the baby's foetal heart rate, support her, or document the care and treatment she provided.


"Following an initial assessment at 4am, the midwife administered pethidine to the woman and sent her home against her wishes and when it was not clinically appropriate to do so," Hill said.

When she reassessed Barlow at home four hours later, Campbell found her to be fully dilated and pushing involuntarily with her contractions.

Campbell transferred Barlow back to the birthing centre in an ambulance.

However, after an hour and a half of active pushing at the birthing centre with no progress, the midwife transferred Barlow to the hospital in an ambulance about 1pm.

Hill found Campbell "did not consult a specialist and/or transfer the woman to secondary care in a timely manner, provide adequate handover information to the public hospital staff, or clarify who was responsible for the woman's ongoing care when the woman was transferred to the public hospital".

Adam was born at the public hospital at 3pm by emergency caesarean section after a prolonged second stage of labour. He could not be resuscitated and died shortly after birth.

Barlow suffered a spontaneous uterine rupture and required emergency surgery, including an abdominal hysterectomy.

She has endured many subsequent operations to correct the injuries she suffered that day.

As well as referring the midwife to the director of proceedings to determine whether any proceedings should be taken, the commissioner recommended she establish a three-year mentoring and continuing education plan with the Midwifery Council of New Zealand and the New Zealand College of Midwives.

Hill also recommended that Campbell complete that plan before returning to work as a self-employed community-based midwife.

He also found the hospital's obstetric registrar in breach of the code for failing to adequately assess the woman and for instigating an inappropriate treatment plan.

Furthermore, Hill concluded Barlow received poor midwifery care from the public hospital midwives, for which the Waikato District Health Board was also found in breach of the code.

Health board chief operating officer Jan Adams said she met Barlow and her husband, Robert, on January 23 to give them a written apology for the board's breach and for inadequacies in the care provided.

"We accept the findings ... In my meeting with Mr and Mrs Barlow, we all took the opportunity to reflect on what happened [and] what we could learn from it."

The board had already introduced several changes, including a new communication checks method for staff called situation background assessment recommendation response.

It would also conduct audits of other processes including transfer of care, admissions and discharges, the cardiotocography (CTG) credentialling process and foetal heart monitoring.

The board also released a joint statement with the New Zealand College of Midwives and the New Zealand Committee of Royal Australian and New Zealand College of Obstetricians and Gynaecologists, in which all three conceded there had been a failure to provide Barlow and her baby safe maternity care.

Fairfax Media