The Health and Disability Commissioner (HDC) has criticised Waikato DHB's care for a woman in her 30s who lost one of her twins in utero.
Waikato DHB – now Te Whatu Ora Waikato – was found to have breached the Code of Health and Disability Services Consumers' Rights over the 2019 incident. The HDC found the DHB did not provide services "with reasonable care and skill" to the woman.
"While she was 12 weeks pregnant with twins, the woman first presented to the hospital's emergency department with headaches and nausea. She required acute management of early onset hypertension," an HDC statement today said.
"At the time there was no effective plan in place to monitor the woman's pregnancy in the community on an ongoing basis.
"The woman was later admitted to hospital with intrauterine growth restriction, as one of the twins had an abnormal heart rate."
She stayed in hospital until her babies' delivery – but it was later confirmed only one fetal heartbeat was present.
"The woman was told that one of her babies had passed in utero," the HDC said.
After learning of the death, the mother wanted to go outside for a cigarette. She was advised against this because of the risk to herself and the live twin – but a midwife took her outside.
There, she had an antepartum haemorrhage. She was rushed back to the delivery suite.
"That same day the twins were delivered by emergency caesarean section," the HDC said.
"While attempts to resuscitate one of the twins were unsuccessful, the other baby was born in good condition."
The woman said that she had repeatedly requested the babies be delivered earlier due to fears for their wellbeing.
She told the HDC: "No one listened to me the night before, I felt my baby die inside of me.
"Against my will I stayed in that hospital for nearly three weeks listening and cooperating with every medical advice given when it concerned my babies and still when I felt her die no one listened."
Te Whatu Ora said the best timing of the delivery was based on clinical indications, and scans "were never abnormal to the point of warranting earlier delivery".
And after learning of the baby's death, the mother spoke to medical staff. She wanted the babies to be "spiritually safe", "dead or alive".
"She told medical staff she needed to ensure [the babies] had whānau to care for them while she was unable to," the HDC said.
"Whānau were not notified, nor was a cultural support person sourced to be with the woman (who is Māori) while she worked through the immediate aftermath of losing her baby."
The mother said she felt her cultural need for family members to greet and care for the babies was ignored.
Deputy Health and Disability Commissioner Rose Wall criticised the DHB over the incident – however, she acknowledged "the circumstances were challenging".
She did not find the DHB had breached the code in respect to that.
She said that cumulative deficiencies in care amounted to the breach of the code for not providing services with reasonable care and skill.
She was critical of Waikato DHB’s care following the first ED review when an effective plan was not put in place to closely monitor the woman’s condition in the community.
She was also critical that medical input was not sought when two separate heartbeats could not be identified clearly, and of the decision over whether to deliver the babies early.
Hall recommended Te Whatu Ora Waikato provide a written apology and train staff on managing hypertension and pre-eclampsia in twin pregnancies.
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