A newborn baby boy was pulled “pale and floppy” from his mother after the decision to perform a caesarean section was delayed by hours.

Now, Health NZ has been found to have failed the mother and has since undertaken major changes to ensure another similar incident doesn’t happen again.

Deputy Health and Disability Commissioner Rose Wall detailed the incident in her finding released today and found the health agency had failed on multiple levels.

“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,” Wall said.

“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.”

According to Wall’s ruling the woman was admitted to the Birthing Suite at Christchurch Woman’s Hospital in 2018 for induction of labour, which started three days after admission.

On the fourth day after hours of trying for a natural birth a decision was made at 11pm to deliver the baby via a caesarian section.

However, doctors then had to wait for the operating theatre to be vacated and then cleaned.

Then, another patient who was in urgent need of care took priority which pushed the woman’s procedure back further.

Two hours later it commenced, but there were issues in getting the baby out and he was described as “pale and floppy” when removed. He was taken straight to a neonatal unit where he needed CPR.

Deputy Health and Disability Commissioner Rose Wall. Photo / HDC

Sadly, the newborn was diagnosed with a brain injury caused by inadequate oxygen and was transferred to the neonatal ICU where he passed away seven days later.

Following the baby’s death, a serious event review report was filed and Health NZ recommended the development of a communication tool between midwifery and obstetrics units, a review of rostering at the hospital, a review of the Caesarean Section guidelines and a suggestion to open a second operating theatre in the birthing suite.

Health NZ expressed its sincere condolences to the mother and her husband and made assurances that improvements had been made to care for both women and their babies.

“The staff of HNZ Waitaha have considerable sympathy with [the family] at their loss and particularly the circumstances in which the death of [Baby A] occurred,” part of its statement reads.

“That event has been devastating for all the staff involved, and there is no doubt that the feelings of [Mrs A] and her husband would be even more extreme.”

In her report, Wall said that the failings covered several stages, with the first being a delay in assessing whether the woman needed a C-section, a lack of appropriate escalation and a delay in actually commencing the operation.

Wall said the decision to recommend a C-section should have been made once an assessment had been done that found that a natural birth wasn’t going to be possible.

“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,” Wall said.

“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 there were multiple systemic issues that affected the care the woman received, which she described as a combination of inadequate staffing and a lack of formal procedure to escalate potentially serious incidents.

“I have taken into account the resource constraints outlined by Health New Zealand,” Wall said. “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.”

Since the event, Health NZ has made a number of changes, which are outlined in the report, including major changes to staffing within the Obstetrics and Gynaecology Department.

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.