“Multiple systemic failures” at Christchurch Women’s Hospital have been cited as the cause of a newborn baby’s death.

In January 2018, the woman involved had been admitted to the Birthing Suite at Christchurch Woman’s Hospital for induction of labour in which commenced three days after her admission.

After labour failed to progress, she underwent a Caesarean section (C-section). The newborn was diagnosed with a brain injury caused by inadequate oxygen and was transferred to the neonatal ICU, where he later passed away.

Deputy Health and Disability Commissioner Rose Wall found Health New Zealand in breach of the Code for failing to provide services with reasonable care and skill.

The breach encompassed several failures in care, including a prolonged first stage of labour, delays in assessment during labour, and a lack of appropriate escalation of care to the second on-call Senior Medical Officer. The diagnosis of failure to progress in labour was delayed, which in turn delayed the decision to recommend a C-section. Furthermore, there was an additional delay in commencing the C-section.

“In my view, the key issue in this case is the delay in diagnosing the failure to progress in labour, and the delay in recommending a delivery by C-section. Given the woman’s high-risk pregnancy, due to an advanced maternal age, IVF pregnancy, and her medical history … it would have been reasonable to take a more conservative approach and to assess earlier,” said Ms Wall.

Wall said decision to recommend a C-section should have been made promptly after the assessment was done. “Given the overall clinical picture, it was clear that there was a failure to progress in labour. In my view, the decision to recommend delivery of the baby by C-section should have been made at this point.”

A further delay of almost two hours occurred once the decision to undertake the C-section was made. This delay was attributed to the operating theatre needing to be prepared and medical staff made available. “I am concerned about the delay in the C-section commencing, particularly as I have already established that the decision to recommend delivery by C-section should have been made earlier,” Wall said.

Wall said multiple systemic issues affected the care provided to the woman. “I consider that a combination of inadequate staffing and support, and a lack of safe staffing escalation processes primarily affected the care provided.”

“I have taken into account the resource constraints outlined by Health New Zealand.

“While I acknowledge these limitations, I remain of the view that the woman was entitled to receive services of an appropriate standard from supported staff.”

Following the death, Health New Zealand implemented several changes, including significant staffing adjustments within the Obstetrics and Gynaecology Department.