Tragedy struck a couple when the husband tried to reach the midwife on a phone next to his wife’s hospital bed, only to find out that the phone had been accidentally switched to “block caller mode”. The next day, their unborn baby tragically passed away in utero.
Following a complaint from the baby’s father about the antenatal care provided at Waitākere Hospital, the Health and Disability Commissioner identified several failures, including the blocked caller mode incident and the lack of proper monitoring.
Deputy Health and Disability Commissioner Rose Wall extended her condolences to the couple for their loss and criticized the hospital for not providing timely and safe services due to the malfunctioning bedside telephone system.
Health NZ Waitemāta expressed deep regret over the incident and apologized to the family. Chief medical officer Laura Chapman acknowledged the findings and immediate changes were made to prevent similar incidents in the future.
The Commissioner found Health NZ in breach of the health consumers’ code for failing to ensure safe and appropriate care. The lack of proper monitoring and communication due to a busy workload were highlighted as contributing factors to the tragic outcome.
Mother’s Early Labour and Concerns
The mother, in her late 20s, arrived at Waitākere Hospital in early labor at 40 weeks and three days’ gestation, reporting reduced fetal movements. Despite abnormal monitoring results, concerns for fetal hypoxia were dismissed, and monitoring was recommended to continue.
The doctor’s misunderstanding of the mother’s previous scans and the lack of communication about the care plan were noted as crucial oversights in the case.
Lack of Monitoring and Communication
Monitoring was not repeated overnight despite concerns raised by the father about reduced fetal movements. The differing accounts between the doctor and midwife regarding the decision not to repeat monitoring were noted, with the midwife’s version deemed more compelling.
The failure to ensure proper monitoring and support for the doctor’s busy workload was criticized, leading to the tragic outcome.
Recommendations were made to deactivate the call-blocking function on all telephones, review the threshold for calling in a second obstetrician, and consider maternal ethnicity as a risk factor for stillbirth in the hospital’s policies.
