This story includes details of stillborn births and may be distressing for some people.

A woman who endured having a stillborn baby felt she was not taken to hospital early enough, and later read over her midwife’s notes and found them riddled with errors.

The midwife has now been censured for multiple failures in her care of several women, two of whom had stillborn babies.

“The numerous failures by [the midwife] represent a pattern of poor care and, overall, the care provided ... was not in keeping with the standard reasonably expected of a midwife,” a Health and Disability Commissioner’s investigation found. says.

The midwife, identified only as Registered Midwife A in the HDC report, is no longer practising and says she has no intention of returning to the profession.

The HDC looked at RM A’s care of seven women and found patient rights were breached in five cases.

One of the women, whose baby did not survive, was identified as “Ms H”, a professional woman knowledgeable about clinical practices.

“Following [the baby’s] death, we spent time looking over [RM A’s] notes and found several errors, including noting down heart rates at times where it was not assessed,” the woman told the inquiry.

“This was extremely frustrating and distressing to me, particularly [given my profession], as correct note-taking is vital and there should not be errors regarding basic facts such as times and heart rate results.”

Ms H said action was not taken early enough to get her to a hospital, and faint or inconsistent heartbeats were accepted by A as normal for many hours during her labour.

“[RM A] also did not check the heartbeat as regularly as she should have (especially given the inconsistent results she was getting), with up to an hour in between checks at times.

“We were subsequently told by our hospital obstetrician that we should have come to the hospital as soon as there were any concerns regarding heart rates,” Ms H said.

The HDC investigation report released today said RM A was self-employed but had access to Health NZ Te Whatu Ora’s maternity facilities and birthing units.

The locations where she worked are not disclosed in the report, for privacy reasons.

‘Multi-organ failure’

The other woman whose baby was stillborn, Ms C, presented with excess thirst and weight loss during the final weeks of her pregnancy.

It was her first pregnancy and she went into labour three days overdue.

After the baby was delivered, Ms C became severely unwell with multi-organ failure and required treatment in the intensive care unit.

She was subsequently diagnosed with acute kidney failure, postpartum haemorrhage, and a severe type of pre-eclampsia. She made a full recovery.

“Health NZ raised concern that no records were shared with Health NZ in relation to any assessments or observations that may or may not have been done by RM A until the point of admission to the birthing unit, when no fetal heartbeat could be heard and Ms C was transferred to hospital,” the HDC report said.

The complaints about RM A were sparked by Health NZ, which wrote twice to the Midwifery Council about her after a senior manager in a public hospital raised concerns about Ms H’s case in 2021.

Health NZ suspended its agreement with the midwife that she could use its facilities at the same time.

It wrote a second time to the Midwifery Council providing a timeline about events involving six other women between 2017 and 2021.

“The circumstances of this investigation are a salient reminder of the importance of professionals ‘speaking up’ when they observe an emerging pattern of poor care or issues of clinical concern,” Deputy Commissioner Rose Wall said.

Wall noted there were “emerging themes” in the investigation regarding the midwife’s practice.

These included documentation not meeting accepted midwifery standards; lack of documentation of consultation with, and handover to, secondary care; sparse documentation of assessments and of phone discussions; a lack of patient history review; a lack of baseline observations to determine fetal and maternal wellbeing during critical stages of labour.

She found the midwife breached the code of health consumers’ rights for failing to provide one of the women with information she was entitled to receive.

Wall found that the midwife breached the rights of three women, for failing to recognise a condition that required consultation with another medical practitioner and failing to perform palpation and maternal baseline observations.

She also failed to monitor maternal and fetal wellbeing and perform ongoing observations at critical stages of labour, or respond with “timely and appropriate interventions” when there were indications of difficulty.

Wall found that the midwife breached patient rights in her care of five women for the standard of her documentation.

‘No intention of returning’

The midwife left the profession when her practising certificate expired three years ago.

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Wall recommended that A formally apologise to the women and, should she return to practice, undertake training recommended by the Midwifery Council.

“I have no intention of ever returning to midwifery,” RM A told the HDC.

“I have spent much time reflecting on this and it has again only served to impact my mental health with a return of stress and anxiety,” she said.

“I realise this is not as great an impact as a stillbirth would be.”

Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.