'Systems failure': Woman had miscarriage after Health NZ failed to escalate care despite multiple ED visits
Photo:
RNZ / Samuel Rillstone
A woman who suffered a miscarriage during her first pregnancy when Health NZ failed to refer her to obstetrics after multiple ED visits is owed a written apology, according to the Health and Disability Commissioner.
According to a decision released on Monday, the woman presented to Wairarapa Hospital five times over the course of her pregnancy.
She was diagnosed with hyperemesis gravidarum, a condition characterised by severe nausea, vomiting, weight loss and electrolyte disturbance. She was given intravenous hydration and anti-nausea medication.
But on her final visit to ED, she was suffering from weakness, dehydration and exhaustion, had several episodes of fainting, and blood test results were abnormal.
She was admitted to the High Dependency Unit, and the following day, transferred to another hospital because of abnormal electrolytes and renal function.
There, an ultrasound scan showed the woman had suffered a septic miscarriage.
The Deputy Health and Disability Commission found in a recent decision the miscarriage was the result of a "systems failure" - specifically, that her care was not escalated to the obstetrics team, and therefore she did not receive appropriate scans to check the health of the fetus.
It also failed to ensure the woman was taking her anti-nausea medication effectively, and did not ensure the woman's discharge summaries were shared with her lead maternity carer.
The written decision said the Deputy Commissioner was "critical of Health NZ for failing to manage the woman's ongoing and severe hyperemesis gravidarum appropriately and proactively and failing to monitor the health of her fetus appropriately".
It ultimately found Health NZ breached the Code of Health and Disability Services Consumers' Rights, which gives every consumer the right to co-operation among providers to ensure quality and continuity of services.
The deputy commissioner recommended Health NZ provide a written apology to the woman, and provide evidence that an education session about new guidelines and patient information had been held for ED staff, and finally, conduct an audit of a sample of discharge summaries to ensure they had all been copied to lead maternity carers.
RNZ has approached Health NZ for comment.
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