A “distracted” midwife who was “rushing” to complete administrative tasks after a birth left the room for 25 minutes - only to come back and find the baby unresponsive. 

She, and the other staff at the hospital fought to revive the newborn, who had just finished breastfeeding, but she died despite being transferred to the Neonatal Intensive Care Unit. 

Now, a coroner has criticised midwife Lesa Haynes for a lack of vigilance and mismanagement of her priorities which resulted in the preventable death of the 30-hour-old baby girl. 

An inquest held in 2023 focused on the postpartum care the couple received, in terms of how they were taught to breastfeed the baby and make sure she was able to both breathe and feed. 

According to inquest findings, which were released today, the baby was born in 2015 at Palmerston North Hospital, and the parents, who cannot be named, were assisted by Haynes in helping the baby latch before she left the room to complete paperwork and other tasks. 

The mother said that at some point during this time, her baby stopped feeding, and she thought this meant she was full and had gone to sleep. Shortly after this, the mother began bleeding and needed to call for a nurse, at which point Haynes returned and noticed that the baby appeared quite still. 

Haynes recalls the baby lying on her back, not breathing, with mottled skin and immediately recognised something was wrong and began attempting to resuscitate her. 

The baby was intubated and then transferred to Wellington Hospital’s Neonatal Intensive Care Unit. However, it was found that the baby had suffered irreversible brain damage due to a lack of oxygen, and the decision was made to take her off life support. 

The cause of death was confirmed as Hypoxic-ischaemic encephalopathy due to neonatal asphyxia during the skin-to-skin contact while feeding the baby. 

‘…We didn’t know any better’ 

The baby’s mother told the inquest that she recalled being surprised at how close the baby needed to be held in order to be fed, and remembers asking Haynes: “Will she be able to breathe?” and being told in response that “The desire to breathe is greater than her desire to feed.” 

She didn’t recall any specific instructions on how to keep the baby’s airways clear, and that after the feeding had finished her daughter appeared to be asleep. 

The baby’s father said that after the skin-to-skin contact and the feeding began, Haynes left the room a number of times. When she returned and saw that the baby was still, she “immediately grabbed the baby and jumped into action.” 

When asked about what he expected in terms of Haynes’ further involvement, he said that they were first-time parents and were in her hands, and it was for her to tell them what to do. 

Coroner Bruce Hesketh at the first day of the inquest in 2023. Photo / Jeremy Wilkinson 

The father said the inquest focused on the breastfeeding, but at the time it didn’t seem like a huge thing because they were told what to expect before Haynes left the room. 

“That didn’t seem unusual or alarming to us, we didn’t know any better. Everything was relaxed, casual and there were no details,” he said. 

‘I can still see that day in my head’ 

Haynes accepted that she was absent for about 25 minutes during the second hour of the baby being born, and that she had left the room multiple times in the first hour. 

“…it would have been for a couple of minutes to get pain relief but with the amount of work that goes on within that first hour or so, there’s no way I left the room for an extended period of time and would have left them alone,” she said at the inquest. 

Haynes explained that once the baby had been born she would keep an eye on the girl’s colour and breathing and checking the placenta and the mother’s perineum. She would also clean up after the birth, position the mother and getting the baby skin to skin. 

In terms of breastfeeding she said that she talked about keeping the baby’s face clear, watching the length of her jaw for sucking, what to look for with swallowing, how to make sure that her face was clear. 

She said she showed the mother how to put her finger on her breast to keep that away from the baby’s face and then got her to repeat that back to her. 

She said she most definitely showed the parents the proper technique for breastfeeding, stating. “I can still see that day in my head, it is very clear, that that’s what I did…I cannot get rid of it”. 

After about five minutes she considered that the mother and baby were fine and that the father was capable of watching them, so she left the room to give them some time alone. 

The coronial inquest took nearly eight years to be heard in Palmerston North. Photo / Jeremy Wilkinson 

The midwife was questioned at the inquest about whether she had an obligation to remain in the room. 

“In hindsight, absolutely, ” she replied. 

Haynes declined to comment further when approached by NZME about today’s findings. 

The death was preventable 

Coroner Bruce Hesketh said in his findings that Haynes had not provided an acceptable standard of maternity care, that it wasn’t appropriate for her to have left the room, and that the baby’s death was preventable. 

“I am satisfied that RM Haynes was rushing to complete her outstanding tasks instead of being vigilant during the very important skin to skin contact and first breastfeed between [the mother] and [the baby].” 

“I do not accept it was appropriate in the circumstances of this case to leave the parents alone at the time she did. It was too soon and there had not been sufficient observation of mother and baby during the first breastfeed.” 

Coroner Hesketh said that Haynes’ priorities were wrong in leaving the room when she did and that she should have stayed longer to observe. 

“I find RM Haynes got distracted when she left the birthing suite and had it not been for the call bell activation and the intervention of [hospital staff], I am satisfied RM Haynes would have been absent for even longer.” 

Coroner Hesketh recommended the Te Whatu Ora review the definition of the “Immediate Postnatal period” in its guidelines, and that this period should not encompass just the first one to two hours post birth. 

Instead, Coroner Hesketh said this period should be an ongoing assessment that recognised any deviations from normality. 

Jeremy Wilkinson is an Open Justice reporter based in Manawatū, covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.