Supporting Families, Preventing Tragedies




Sunday, 30 August 2009

A missed diagnosis cost your life; it should have been different.

You kicked last night; today you are dead – no heart beat, no movement on the ultrasound. I delivered you 1 day early. Long fat legs, 7 pounds 3, you looked perfect; your life cut short because of a missed diagnosis.

Pregnancy induced cholestasis is a rare condition but with classic symptoms: itchiness with no obvious rash, weight loss, nausea, concentrated urine. I had all these symptoms but underplayed the severity of them in the stoic way I approach life. My midwife knew I was stoic and should have investigated my comments about being ‘a bit itchy’!

Her history taking and clinical exam skills failed us. The fact I was unwell and had lost weight alone should have been followed up. Instead, brushed aside, my bile salts were left to rise reaching 52 (the risk of still birth is high when levels rise above 40).

Had my urine been collected into a pottle she would have had another clinical indicator to make her investigate my comments and glean more history from me to help her realize I was at risk. The outcome should have been different; blood tests would have highlighted the condition, I would have been induced and Eleanor Grace would have arrived crying and kicking.

The post natal confrontation with this midwife was also a let down. It was distressing to confront the midwife about her failure. I wanted to give her a clinical paper detailing the condition for her to read and share with the other midwives working in Westport. On leaving she suggested I needed ‘medication’ – I presume she meant for depression. This was only 8 wks out from the event. It highlighted to me her lack of understanding about what I had been through and how stressful it was confronting her. Unfortunately her boss was unaware of the case because I delivered in Christchurch. As a result the case was not discussed openly so that learning could be achieved from this incident. This has since happened after I initiated a meeting with the head midwife in Greymouth, 9 months after the event.

My case highlights several failures in the NZ maternity care system: lack of skills, knowledge and team work; lack of accountability and discipline (which would happen if it were a doctor involved) and inadequate debriefing, learning for the midwives and patient support.

I strongly support a review of the NZ maternity care system. I believe we need to bring back the hospital based care with doctors, nurses and midwives working together. There are too many families that have suffered at the hands of our current system.

Lynn and Glenn

Red Flags

        RED FLAGS

  • Lack of monitoring
  • “Normalising” the abnormal
  • Lack of action/delay in getting emergency care
  • Going over due date
  • Failure to progress in labour
  • Meconium-stained liquor (waters)
  • Lengthy handover during emergency
  • Inconsistent reporting and documentation
  • Your concerns being ignored

    Click here to read more about common warning signs

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