Hospital Communication Failure Leads to Stillbirth Tragedy

A couple’s attempt to contact hospital staff about their unborn child’s wellbeing ended in tragedy when their baby was stillborn at Waitākere Hospital. The incident occurred after the husband of a woman who was 40 weeks pregnant attempted to use a bedside phone to reach a midwife. Unfortunately, the phone was inadvertently set to “block caller mode,” preventing any communication. The baby was confirmed to have passed away in utero the following day.

This communication failure was highlighted by the Health and Disability Commissioner, who identified multiple shortcomings in the antenatal care provided to the mother at the hospital. Following a complaint from the baby’s father, Commissioner Dr. Wall criticized the hospital’s inadequate telephone system, stating it created a barrier to timely and safe medical services.

The investigation revealed that Health New Zealand breached the health consumers’ code by failing to manage care safely and appropriately. In particular, it was found that intermittent cardiotocography (CTG) monitoring was not conducted as required due to the consultant obstetrician’s heavy workload, leading to poor communication regarding the care plan.

Timeline of Events Leading to the Tragedy

The mother, in her late 20s, arrived at Waitākere Hospital for assessment at 40 weeks and 3 days of gestation. She was experiencing early labor and reported reduced fetal movements. Two days prior, CTG monitoring had indicated reduced activity. Upon her return to the hospital, the monitoring showed an absence of fetal heart rate accelerations and some shallow decelerations. Despite these abnormalities, the consultant obstetrician did not believe they indicated fetal hypoxia, a condition marked by reduced oxygen supply to the baby.

After the mother was admitted, her care was transferred to a midwife, who instructed the couple on how to use the bedside telephone to communicate any concerns. Over an hour later, the doctor reviewed the CTG monitoring and acknowledged its abnormality, yet determined that fetal hypoxia was not evident.

Dr. Wall noted that the obstetrician was occupied with multiple patients that night, which complicated the management of care. Hospital policy required a second obstetrician to be called if two concurrent interventions were necessary. The doctor, however, opted not to call for additional assistance, believing the interventions were sequential.

Throughout the night, the midwife saw the mother several times. The couple expressed concerns about the baby’s movements, requesting that monitoring be resumed. The midwife’s account suggested that she was not fully informed of the couple’s worries, aside from a mention of light spotting by the mother. Monitoring only recommenced at 6:50 AM, at which point no fetal heartbeat could be detected, confirming the baby had died.

Inconsistencies and Recommendations

Dr. Wall pointed out inconsistencies in the accounts of the midwife and the doctor regarding why CTG monitoring was not repeated overnight. Ultimately, she found the midwife’s testimony more credible. An Adverse Event Review (AER) by Health New Zealand Te Whatu Ora acknowledged the discrepancies in their statements, confirming that CTG monitoring should have been conducted during the night.

Dr. Wall expressed concern that the obstetrician was managing responsibilities beyond the capacity of one senior medical officer, highlighting the need for adequate support systems in hospitals. She emphasized that Health New Zealand must ensure that sufficient skilled staff are available to provide safe and timely care.

In her recommendations, Dr. Wall insisted that the call-blocking function on hospital telephones be deactivated to prevent future communication barriers. She also suggested a review of hospital policies regarding the circumstances under which a second obstetrician should be called. Furthermore, she recommended that the hospital consider including maternal ethnicity as a risk factor for stillbirth in their guidelines on reduced fetal movements.

This tragic incident underscores the critical importance of effective communication and thorough monitoring in maternity care, as well as the need for systemic improvements to safeguard the wellbeing of both mothers and their babies.