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Nurse criticised after newborn dies during post-birth care lapse

Nursing investigation
Stock photo.

A Health and Disability Commissioner ruling has found a registered nurse failed to properly monitor a newborn who died shortly after birth in 2019, breaching required care standards.

The baby, delivered healthy at 38 weeks, was placed skin-to-skin with his mother while she underwent suturing for a tear, but was not directly checked by the nurse for around an hour.

During this time, the nurse relied on the mother—who was using nitrous oxide for pain relief—for updates on the baby’s condition, despite being unable to see the infant clearly.

When the nurse later attempted a full assessment, the baby was unresponsive and could not be revived, with a post-mortem attributing the death to probable accidental asphyxiation.



The commissioner concluded the nurse should have ensured continuous direct monitoring or delayed the procedure, noting guidelines require ongoing assessment and that mother and baby should not be left unattended. The nurse accepted the breach and later retired from practice.

Image credit: Nathan Dumlao

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5 COMMENTS

  1. So somehow the mother accidentally smothered the baby????

    I mean I get the mum maybe shouldnt have been left alone but honestly having had THREE babies there are multiple times I have been left alone after the birth. Although most of the time my husband was there. But seriously what was the MUm doing? Where was her family or support person? Seems to me thr midwife had a lot on her plate with the surture. Our whole maternity system was and is terrible. It’s all about the money and making sure money is not wasted on a woman when she’s at her MOST vulnerable. It’s disgusting. I don’t think you can fully blame the midwife here.

    • Can’t know for sure without more details. Maybe the mum still had nitrous/anaesthetic or whatever else in her system and was a bit out of it. Or maybe she was just an imbecile… doesn’t matter.

      You absolutely CAN blame the midwife, her literal job is to watch over the infant at that point in time. Isn’t the suture the doctor’s area of concern? How can the mother be held responsible when she hasn’t undergone any formal training or logged hundreds of hours of experience in neo natal childcare like the nurse? Isn’t the entire point of having these armies of doctors and nurses and midwives BECAUSE it’s assumed most new parents are idiots and don’t quite yet know exactly what they’re doing at that very moment in time?

      I understand it’s not nice to point fingers and all, and it certainly won’t bring the child back… but the blame here is clearly on the midwife.

  2. Why on earth does it take 6 years for that Commission to finally make such statement?
    Pull out finger and get your job done promptly!
    Keeping all parties, ie all affected people in limbo for soo long is abhorrent, to say the least.

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