The Waikato District Health Board has apologised to a woman for failings in her care after her uterus ruptured, and her child died a month later.
Waikato DHB has been criticised for deficiencies in the Obstetric and General Surgery reviews. Photo: RNZ / Dan Cook
The woman entered hospital at 28 weeks pregnant with abdominal pain but the obstetric and surgical teams could not find the cause before she collapsed 17 hours later with a ruptured uterus.
The baby initially survived but died a month later as a result of birth hypoxia.
The deputy Health and Disability Commissioner Rose Wall found the DHB breached its code of care with deficiencies in the medical professionals' reviews, including missed opportunities for senior oversight.
Deputy Health and Disability Commissioner Rose Wall today released a report finding Waikato District Health Board in breach of the Code of Health and Disability Services Consumers' Rights (the Code) for the care provided to a pregnant woman.
Wall noted that the rupture of an unscarred uterus in a non-labouring woman was extremely rare and it was not a diagnosis that would have been considered or made by many clinicians in the circumstances.
However, she criticised Waikato DHB for deficiencies in the Obstetric and General Surgery reviews. These included missed opportunities for increased senior oversight and inadequate documentation of some reviews.
Wall also said a lack of effective communication and co-ordination between the Obstetrics and General Surgery teams contributed to a delay in appropriate radiological assessment.
She recommended that Waikato DHB report on the action points identified in its Serious Incident Review Report; provide evidence of recent staff training on co-ordination of care, escalation of care, and documentation; use the report as a basis for staff training; and report back on its implementation of the New Zealand National Maternity Early Warning system (MEWS). All recommendations were subsequently complied with.