DHB, doctor at fault for harm to baby at birth
A Canterbury baby was left with a fractured collarbone, bruises and long-term developmental delays after a junior doctor and the district health board failed to provide proper care during her birth.
Health and Disability Commissioner Anthony Hill released a report into the botched delivery yesterday, finding an obstetric registrar and the Canterbury District Health Board failed to provide appropriate care to a first-time mother during the birth of her daughter in 2011.
The 34-year-old mother had a history of diabetes and went into labour about three weeks early.
She was monitored by staff at one of Christchurch's public hospitals for about 20 hours before an obstetrics register, named in the report as Dr B, noticed signs of foetal compromise and decided to deliver the baby using instruments.
The doctor tried five times to use a vacuum-like device to deliver the baby, before switching to forceps.
The baby had to be resuscitated and responded well, but began displaying unusual movements about two hours later and was transferred to the Neonatal Intensive Care Unit.
An MRI scan showed she had suffered bleeding between the periosteum and scalp and severe lack of oxygen during birth. An X-ray later revealed a fractured collarbone.
She still had weakness in her left arm and leg, and had shown delays in motor development.
Hill found the registrar failed to recognise the complexity of the situation and made a "series of poor clinical decisions", including failing to contact the on-call consultant and proceeding with an instrumental delivery instead of a caesarean section.
Hill said the health board also failed the family because it did not have a culture that "sufficiently supported" the registrar, and placed responsibility on junior staff to recognise the extent of their own expertise.
Dr B apologised for the incident, saying the responsibility for the decisions made "lies with me". "I made the best decisions I could at the time with the best interests of [Baby A] and [Ms A] at heart. However, in retrospect I wish I had made a different decision or recommendations."
Health board chief medical officer Dr Nigel Millar said a letter of apology had been given to the commissioner for the mother and her family.
"This is a tragic event for this family. While we cannot change what has happened, much as we would like to, we can work to reach the highest possible standard of care and thereby limit the chances of this problem recurring."
The health board had since introduced new guidelines for the supervision of registrars, a new training programme for staff carrying out instrument deliveries, and weekly meetings for reviewing complex labours that resulted in emergency caesarean sections, Millar said.