The ultrasound scan at Pacific Radiology showed low amniotic fluid and a drop in foetal weight. Photo: 123rf
- Care was delayed for a pregnant woman and her stillborn baby because the results of a post-date scan were not sent
- The Deputy Health and Disability Commissioner have found both a radiology clinic and midwife in breach of her rights
- They have since made changes
A radiology clinic and registered midwife have been found in breach of a pregnant woman's rights by failing to follow up on the results of a significant post-due date scan.
Deputy Health and Disability Commissioner Rose Wall says care for the woman, and her stillborn baby, was delayed as a result.
The report from the deputy commissioner, released today, has found the rights of the woman and her baby were breached under the Code of Health and Disability Services Consumers Rights.
At just over 41-weeks pregnant, the woman was sent to Pacific Radiology by her midwife for a post-due date ultrasound scan.
The scan showed low amniotic fluid and a drop in foetal weight, but the woman was reassured that was normal for her stage, and told the results would be sent to her midwife.
The results of the scan were significant and required priority communication - but Pacific Radiology did not send the findings to the midwife due to a coding error, nor did staff follow up with a phone call or other checks to make sure the findings were sent, Wall said.
The midwife did not discover the results had not been sent until the woman began bleeding and felt reduced foetal movement.
She was taken to hospital, where the baby was induced and stillborn.
The responsibility for communicating the findings rested with the clinic, not the patient, Wall said.
"I am highly critical that Pacific Radiology was aware that it was using an IT system that held 'empty' codes, which, if selected, would result in the report in question going nowhere," she said.
"I am also critical that it appears that no checking systems or policies were in place for such cases... whether that be within the system itself, and/or follow-up by frontline staff."
The midwife held the ultimate responsibility to follow up on the results, and by failing to do so, delayed care for the woman and her baby, Wall said.
The radiologist who conducted the ultrasound should have followed up to ensure the results of the scan were communicated to the midwife, she added.
Pacific Radiology and the midwife have since made changes to improve communication.