A woman suffered a stillbirth after a specialist missed her symptoms of an infection. 

A woman in her third trimester of pregnancy experienced a stillbirth after a specialist missed “red flag” symptoms of an infection and sent her home without further investigation. 

If the woman had been admitted, the baby likely would have survived, findings released today by the Health and Disability Commissioner reported. 

According to the findings, the woman presented at a public hospital when she was 33 weeks pregnant, with clear vaginal discharge and abdominal pain. She was prescribed antibiotics, pain relief and steroids. 

Four days later a scheduled scan found she had reduced amniotic fluid, and the discharge was changing colour. Her abdominal pain remained. She was booked for an induced labour two weeks later, discharged and advised to return to hospital if she had concerns. 

The following day, the woman returned to the maternity unit, as she was experiencing contractions. A foetal heartbeat couldn’t be found and the baby was found to have died in utero. 

Deputy commissioner Rose Wall said in her findings that the presence of green discharge and abdominal pain should have raised concerns with the consultant obstetrician and gynaecologist as placing the foetus at risk. The woman should have been admitted to the maternity unit for further investigations. 

She found the decision to discharge the woman was a severe departure from accepted practice and as such the doctor had failed to provide the woman with reasonable care and skill. 

Independent advice prepared for the commission by Dr Judy Ormandy, a senior lecturer in obstetrics and gynaecology and women’s health based at the University of Otago, Wellington found the decision to discharge the woman was “a severe departure from accepted practice.” 

“The crux of this case is that [the woman] was incorrectly discharged from her maternity assessment. Had she at that point been admitted to hospital and delivery via induction of labour or caesarean section occurred, it is likely the baby would have survived. 

The consultant accepted the woman should have been admitted to the maternity unit. He told the commission he could not understand why he discharged the woman when he did. 

“I still cannot think of any human factors that might be relevant as, although they would not have excused my mistake, they might have explained why it occurred. 

“Their absence is a concern to me, as I would like to understand why I made such a basic mistake. I cannot reverse it (unfortunately) but would like to have better confidence that I wouldn’t make such a mistake again.” 

The consultant met with the woman, apologised, and further researched the subject. The Medical Council has also been provided with a partly anonymised copy of the decision and advised of the doctor’s name. 

Health NZ has developed a pamphlet providing advice for women who are self-monitoring at home with preterm rupture of membranes. 

Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist for 20 years, including at the Waikato Times and RNZ. Most recently she was working as a media advisor at the Ministry of Justice.