A woman repeatedly told her obstetrician she was worried about her baby's growth. Four days after he dismissed her concerns, her son was stillborn.
The Health and Disability Commissioner has found Health New Zealand breached the Code of Health and Disability Services Consumers' Rights over the care provided to the woman at Southland Hospital in 2021. The finding centres on a failure to appropriately manage abnormal ultrasound findings and intrauterine growth restriction (IUGR).
The woman, who has name suppression, became pregnant via IVF in 2021. Scans from August that year showed the fetus was growing below the 5th percentile — a possible sign of IUGR. A further ultrasound on September 14 uncovered an abnormal Doppler finding, but it was not included in the opinion section of the sonographer's report. That omission would have consequences.
Eight days later, on September 22, she attended the antenatal clinic at Southland Hospital and saw a locum obstetrician. She said he had no access to her notes. "I had to share my own LMC notes … which he barely glanced at," she told the HDC.
When she tried to raise her concerns, she was brushed off. "I had to stress to him that my LMC and sonographer were 'very concerned' about fetal growth," she said. She left feeling unheard.
Health NZ told HDC the department was "critically short-staffed" and under "extreme pressure" managing Covid-19 at the time, with "little opportunity for orientation for locums".
The clinic letter the doctor produced recorded that the woman reported good fetal movements — something she disputes — and noted the Dopplers and liquor volume as normal. The abnormal Doppler finding from September 14 had not made it into the opinion section of the report he was working from. Health NZ later accepted that further investigations should have been undertaken.
Standard management for IUGR, Health NZ told HDC, is weekly ultrasound with Dopplers. If abnormal results appear, twice-weekly scans. If those worsen, delivery. None of that happened.
On September 26, the woman contacted her lead maternity carer because the baby had stopped moving. At Southland Hospital, an ultrasound confirmed her son had died. She delivered him by emergency caesarean section.
"What could we do? He was the obstetrician," she told the HDC. "We had finally been able to see a specialist after delays, I just wish it was someone who did their job properly so our son could have had a fighting chance."
The hospital did not conduct an adverse event review after the stillbirth. Deputy Health and Disability Commissioner Rose Wall was direct about what that meant. "Southland Hospital did not undertake an adverse event review after the stillbirth of [the baby]. In my opinion, this was a valuable opportunity for its obstetric service to learn from this episode and make the necessary changes to its systems and processes to help prevent a repeat of [the couple's] tragic loss."
Wall identified the failures as systemic. "I consider that these shortcomings represent systemic failures for which ultimately Health NZ is responsible at an organisational level."
The woman said the family wanted something to come from what they went through. "We understand that as humans we all make mistakes and that in order to progress, we need to own it, fix it and learn from it. Although there is nothing that can be done to fix losing our precious son, there are learnings that can be taken from our experience, to help improve our health system for other expecting mothers. We left the hospital that day feeling dismissed, not listened to and feeling really uneasy about the situation."
Health NZ chief medical officer southern David Gow said the organisation was "deeply sorry" and acknowledged "the profound long-lasting impact". He said improvements had since been made, including recruiting a full team of eight consultants and establishing a locum induction guide. "We only now use regular locum staff, who are very familiar with our service, and these staff are supported by a locum induction and orientation guide that has been established with the assistance of a regular highly-experienced locum," Gow said.
The woman also waited nine months for a follow-up debrief she had been promised within six months. Health NZ apologised for that delay too.
The commissioner has recommended Health NZ report back within three months on the effectiveness of changes to its obstetric service.