A Health and Disability Commissioner (HDC) investigation has found multiple failures in the antenatal care of a woman at Waitākere Hospital, whose baby was stillborn after her husband was unable to reach the midwife because the bedside phone had been accidentally switched to “block caller mode.”
The inquiry found Health New Zealand breached the Code of Health and Disability Services by not ensuring safe, timely care, with Deputy Commissioner Rose Wall criticising the faulty phone system and the lack of repeated cardiotocography (CTG) monitoring despite abnormal readings and reduced fetal movements.
Miscommunication between staff, including a consultant obstetrician who mistakenly believed a recent scan had been completed, further contributed to gaps in care.
The commissioner also found that an overworked obstetrician, managing more cases than appropriate for one senior doctor, failed to restart monitoring overnight, while the midwife and doctor offered conflicting accounts about concerns raised by the parents.
CTG monitoring did not resume until 6.50am, when no fetal heartbeat could be found. Recommendations include disabling call-blocking on patient phones, reviewing obstetric staffing policies, and updating guidelines for managing reduced fetal movements.
Image credit: João Paulo de Souza Oliveira
