A woman who experienced a stillbirth has criticized the timeliness of her hospital transfer and found numerous errors in her midwife’s records. The midwife, now censured, faced scrutiny for inadequate care of several women, including two who suffered stillbirths.
According to a Health and Disability Commissioner (HDC) investigation, the midwife’s repeated failures reflect a troubling pattern of substandard care that did not meet professional expectations. The midwife, referred to as Registered Midwife A in the HDC report, is no longer practicing and has stated she does not plan to return to the profession.
The HDC reviewed the midwife’s care of seven women and found breaches of patient rights in five instances. One of these cases involved a woman identified as Ms. H, who discovered multiple errors in the midwife’s notes after her baby’s death. Ms. H, a professional familiar with clinical practices, noted incorrect heart rate recordings and errors in time documentation. She expressed frustration, emphasizing the critical nature of accurate record-keeping.
Ms. H reported that the midwife did not act promptly to transfer her to a hospital and failed to monitor fetal heart rates regularly, sometimes going an hour between checks. Hospital obstetricians later advised that the woman should have been brought to the hospital as soon as any concerns arose.
Another woman, Ms. C, experienced severe complications after delivering a stillborn baby. Presenting with excessive thirst and weight loss in her final weeks of pregnancy, Ms. C went into labor three days overdue. Post-delivery, she suffered from multi-organ failure, acute kidney failure, postpartum hemorrhage, and severe pre-eclampsia but eventually recovered.
The HDC report noted that Health NZ had concerns about the lack of shared records from the midwife until Ms. C’s admission to the hospital when no fetal heartbeat was detected. Health NZ initially raised issues with the Midwifery Council in 2021 and subsequently suspended its agreement with the midwife.
Deputy Commissioner Rose Wall highlighted the investigation’s findings, noting that the midwife’s documentation failed to meet standards, lacked adequate consultations and handovers, and omitted critical patient observations. Wall found that the midwife breached health consumer rights by not providing necessary information and failing to recognize conditions requiring additional medical consultation.
The report also identified failures in monitoring maternal and fetal well-being and responding appropriately during critical labor stages. Wall’s recommendations include a formal apology from the midwife and mandatory training if she ever returns to practice. However, the midwife has stated she has no intention of resuming her career, citing the emotional toll and ongoing stress caused by the case.
“I have spent much time reflecting on this and it has again only served to impact my mental health with a return of stress and anxiety,” she said, acknowledging the severity of the situation compared to the stillbirths.
