Deputy Health and Disability Commissioner Rose Wall today
released a report finding Waikato District Health Board in
breach of the Code of Health and Disability Services
Consumers’ Rights (the Code) for the care provided to a
The woman, who was 28 weeks pregnant,
presented to the public hospital with abdominal pain.
Assessments by the obstetric and general surgical teams had
not established a cause for the pain before the woman
collapsed 17 hours later and was found to have a ruptured
uterus. The baby initially survived, but died a month later
as a result of birth hypoxia.
Ms Wall noted that the
rupture of an unscarred uterus in a non-labouring woman is
extremely rare and, prior to the woman’s collapse, it was
not a diagnosis that would have been considered or made by
many clinicians in the circumstances. However, the Deputy
Commissioner criticised Waikato DHB for a number of
deficiencies in the Obstetric and General Surgery reviews.
These included missed opportunities for increased senior
oversight and inadequate documentation of some
Ms Wall also considered that a lack of
effective communication and co-ordination between the
Obstetrics and General Surgery teams contributed to a delay
in appropriate radiological assessment.
recommended that Waikato DHB report on the action points
identified in its Serious Incident Review Report; provide
evidence of recent staff training on co-ordination of care,
escalation of care, and documentation; use the report as a
basis for staff training; and report back on its
implementation of the New Zealand National Maternity Early
Warning system (MEWS). She also recommended that the DHB
apologise to the woman and her family. These recommendations
have been complied with.
The full report for case
17HDC00453 is available on the HDC
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