Hospital Communication Failures Linked to Stillbirth Tragedy

A series of communication failures at Waitākere Hospital has been linked to the stillbirth of a baby born to a woman who was 40 weeks pregnant. According to the Health and Disability Commissioner, a key factor in this tragic outcome was the inability of the woman’s husband to reach hospital staff via a bedside telephone that had been inadvertently switched to “block caller mode.” The incident has raised serious concerns about the safety protocols in place at the facility.

On March 7, 2024, the mother, then in her late 20s, arrived at Waitākere Hospital for assessment at 40 weeks and three days’ gestation, reporting reduced fetal movements. This worrying sign had already been noted two days prior during a cardiotocography (CTG) monitoring session, which tracks fetal heart rate and uterine contractions. Upon her return, the CTG readings were classified as “abnormal.” Despite this, the consultant obstetrician did not believe the situation indicated fetal hypoxia, a condition marked by reduced oxygen supply to the baby in utero.

The circumstances surrounding the mother’s care deteriorated further as the obstetrician became overwhelmed with multiple responsibilities. An hour after her arrival, care was handed over to a midwife, who informed the couple how to use the bedside phone to raise concerns. The father later attempted to call but was unable to connect with the staff when he sensed something was wrong.

The Health and Disability Commissioner, Morag Wall, emphasized that the telephone system’s failure constituted a significant barrier to timely care. She stated, “I consider that this was a barrier to the provision of timely and safe services.” The investigation found that Health New Zealand breached a section of the health consumers’ code by failing to manage care safely and appropriately.

In her findings, Wall highlighted that intermittent CTG monitoring was not conducted as required, primarily due to the obstetrician’s busy schedule, which led to poor communication regarding the care plan. Despite the mother expressing concerns about reduced fetal movements, monitoring did not resume until 6:50 a.m. the following day, at which point no fetal heartbeat could be detected.

Discrepancies in accounts provided by the midwife and the obstetrician regarding the decision to forgo overnight monitoring were noted. Wall found the midwife’s account more credible, suggesting that critical information about the mother’s condition was not adequately communicated.

An Adverse Event Review (AER) conducted by Health New Zealand also revealed significant differences in the narratives provided by the medical staff involved. Wall criticized the hospital’s policies, stating that it was alarming that one medical officer was managing responsibilities beyond their capacity. She stressed the need for adequate support systems to ensure that such oversight does not occur again.

Wall’s recommendations included deactivating the call-blocking function on all bedside telephones and ensuring that staff are aware of any future instances of blocked calls. She also called for an update to hospital policies, particularly regarding the threshold for calling in a second obstetrician when required.

The findings reflect a broader concern regarding the adequacy of care provided to expectant mothers, particularly those experiencing complications. Wall recommended that Health New Zealand consider amending its policies to incorporate maternal ethnicity as a risk factor for stillbirth, underscoring the need for a more nuanced approach to antenatal care.

This heartbreaking incident serves as a reminder of the critical importance of effective communication and thorough monitoring in maternity care. In the wake of this tragedy, the focus now shifts to ensuring that such failures do not occur again, safeguarding the health and wellbeing of future mothers and their children.