The devastating outcome led the first-time mother to file a complaint with the Health and Disciplinary Commission to ensure the system makes changes and incidents like this never happen again.
Now, the Deputy Health and Disability Commissioner has found Pacific Radiology and the midwife breached the woman’s right to care by not sending the scan through and not following up on it.
“I extend my heartfelt condolences to Ms A and her partner for the loss of their precious baby daughter, Baby A,” Deputy Commissioner Rose Wall said in a decision released today.
She said the findings of the scan were significant and required priority communication to the midwife but a “coding error” meant they weren’t sent.
“I am highly critical that Pacific Radiology was aware that it was using an IT system that held ‘empty’ codes, which, if selected, would result in the report in question going ‘nowhere’.”
“I am also critical that it appears that no checking systems or policies were in place for such cases…whether that be within the system itself, and/or follow-up by frontline staff.”
The 41 week scan
The 2021 pregnancy was largely uneventful though earlier scans showed a low-lying placenta and slowing growth in the lower percentile.
“This was categorised as an ‘unexpected finding’ that could result in significant morbidity if not treated appropriately.”
He marked the report as urgent and assumed the report would be sent to the midwife, despite an internal policy that required action for critical results.
However, the wrong code was entered when the report was being sent and the results essentially went nowhere.
The radiologist did not follow up, and although the midwife was wondering where the scan was and consistently refreshing her phone for updates, she failed to chase it up.
Days later, Ms A noticed her baby was not moving as much and she began spotting. When she called her midwife, she told her to monitor her movements for the next hour.
She then retrieved the scan results and immediately referred her client to the hospital.
Unfortunately, that came too late and Ms A’s baby girl was born stillborn.
At a hearing before Deputy Health and Disability Commissioner Rose Wall, Pacific Radiology, the radiologist and the midwife all gave evidence.
The radiologist said he made assumptions that Ms A would advise her midwife about the findings and also assumed the scan would make its way to her.
“I consider that amniotic fluid volume of (what was at the time incorrectly noted as) 0.8mm should have prompted urgent action to such or at least a similar degree.
“The fact that no phone call was made on Month 9, nor the following day, has not been explained adequately.
“Although the sonographer’s and radiologist’s assumption that Ms A would be in touch with [the midwife] on the day of the scan was not wrong, their expectation that Ms A would convey the relevant clinical findings was unfounded and should not have been expected of the patient,” Wall said in her decision.
Wall also found several failings with the midwife in her failure to follow up on results and advice when Ms A noticed her baby had limited movement.
When Ms A reported spotting and unclear fetal movements the midwife did not immediately arrange for her to be assessed, as current guidelines recommend for symptoms of decreased fetal movements.
Instead, the advice to monitor the baby’s movements for an hour and call back if concerns persisted was no longer considered best practice the decision said.
The Deputy Health and Disability Commissioner found the midwife breached the Code of Health and Disability Services Consumers’ Rights for failing to provide services with reasonable care and skill.
Her actions were considered a moderate departure from accepted midwifery practice, though her assumptions were partly mitigated by her reliance on prior experiences and systemic issues at Pacific Radiology.
Pacific Radiologists were also breached because of a flawed IT system, failure to communicate and inadequate policies around urgent findings.
Pacific Radiologists were ordered to issue a written apology, implement daily checks to reports and add safeguards to prioritise urgent cases.
Since the incident, Pacific Radiology has made several changes to address the systemic issues that contributed to the communication failure.
