A pregnant woman who suffered three haemorrhages before her baby was stillborn was discharged from Auckland Hospital without being given the necessary information and advice, or adequate follow-up.

Following the stillbirth in 2013, the woman complained to the Health and Disability Commissioner (HDC) about several aspects of her care, including that an ultrasound wasn’t carried out when she was admitted to hospital, the discharge information provided by the hospital and the discussions with her midwife following her discharge.

Initially, the commission refused to investigate but following an Ombudsman’s review and more information, it launched an investigation in 2021.

The results of that investigation have been released today.

According to the HDC report, it was the woman’s second pregnancy and, because of problems with her first, she was categorised as high risk.

The woman’s third episode of bleeding occurred at 30 weeks gestation and followed two previous episodes at 16 and 18 weeks.

On her third episode, the woman was transferred to Auckland Hospital for observation.

Initially, an ultrasound was requested but then cancelled after it was discovered she had had one the week before.

By the following morning, her bleeding had settled, and she was seen by an obstetrician who recommended that she stay in hospital for another day and have a second urine test. But no test results were provided.

Because her bleeding had settled, she was sent home into her midwife’s care. But the woman told the HDC that when she was released, she wasn’t advised of the importance of monitoring changes in foetal movements.

She told the HDC neither she nor the midwife were given discharge papers and a growth scan was booked for three weeks’ time.

An electronic discharge plan was created but the Auckland District Health Board acknowledged that “there was clearly an error in communication regarding the need to inform the LMC of the discharge”.

It said the standard practice at the time was to inform the LMC of discharge, but the midwifery staff member who wrote the clinical note wasn’t aware of the process.

The woman produced text messages between her and her midwife, showing there was no discussion with her about discharge and didn’t facilitate any communication with her.

The midwife retrospectively noted that she had spoken to the woman the day after she left hospital, but the woman told the HDC there was no phone call with the midwife after she went home.

The midwife gave evidence that the woman didn’t contact her before the pre-arranged antenatal appointment.

There are conflicting accounts as to what occurred and what was discussed at that appointment.

The woman said she raised concerns about the foetal movements and said she told the midwife the baby’s movements had changed significantly. But the midwife said the woman didn’t raise concerns, and the foetal movements were normal.

The HDC also raised concerns about the midwife’s record-keeping, in particular her failure to make any contemporaneous notes.

At 32 weeks, the woman went into premature labour. When medical staff were unable to find a heartbeat, it was confirmed the baby had died in utero.

The woman laboured and gave birth to a daughter.

HDC findings

In its decision, the HDC said it was unable to reconcile the differences in clinical opinion and found the failure to undertake an ultrasound did not amount to a breach of the Health and Disability Code.

But it found aspects of the woman’s care during her admission to Auckland Hospital fell short of an acceptable standard of care.

In particular, the woman was discharged without a clearly documented rationale as to why there was a departure from the initial plan for her to remain in hospital for 24 hours after obstetric review, and to undertake a repeat urinary protein/creatinine ratio (PCR) test,“ the report said.

There was also a lack of clinical follow-up within appropriate timeframes, and the woman wasn’t given necessary advice (either written or verbal) in relation to monitoring foetal movement.

It also found her discharge information wasn’t communicated to either the referring hospital or her midwife.

These issues meant that the woman was not provided with reasonable care and skill, and, accordingly, the Commissioner found that the board had breached the code.

The commissioner made adverse comment about the information provided to the woman by the midwife, specifically in relation to what was discussed about foetal movements and further monitoring, and what was actually understood.

But the commission was unable to make a finding as to the exact information provided, partly because of the standard of the midwife’s documentation.

The midwife said she had taken the complaint very seriously and this was the first complaint she had received in many years of practice.

“I ... realise after much reflection of this case that my documentation needed to reflect the care and information I provided,” the report quoted the midwife.

The commission recommended that the board apologise to the family and also to consider whether the guidelines relating to investigations for women who presented with antepartum haemorrhages should be clarified.

It also recommended that the midwife provide the HDC with evidence of any workshops or training sessions she had completed on monitoring foetal movements and foetal wellbeing in pregnancy.

Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist for 20 years, including at the Waikato Times and RNZ. Most recently she was working as a media adviser at the Ministry of Justice.