09HDC01592 - Health and Disability Commissioner

Health and Disability CommissionerDr EWhether Dr E provided Mrs A with an appropriate standard of care duringher labour and delivery of Baby A.The DHBWhether the DHB maternity services provided Mrs A with an appropriatestandard of midwifery care.10. An investigation into the actions of the midwives was commenced on 18 September2009. On 3 November 2009, the investigation was extended to include the obstetricregistrar, Dr E. The parties directly involved in the investigation were:Mrs AConsumerBaby A (dec)ConsumerMr AComplainantMs B Provider/LMC midwife 5Ms C Provider/LMC relieving midwife 6Ms D Provider/hospital midwife 7Dr EProvider/obstetric registrar11. Information was also reviewed from:Dr FConsultant obstetricianDr GConsultant obstetricianAssociate Professor Jenny Westgate Obstetrician/ACC adviserAnn YatesMidwife/ACC adviser12. Mrs A‘s antenatal reports, her hospital maternity records, and the clinical recordsfrom the large centre neonatal unit were all obtained, together with the ACC treatmentinjury decision dated 30 November 2009.13. Independent expert advice was obtained from midwife Mrs Christine Stanbridge(Appendix A) and from obstetrician Dr Ian Page (Appendix B).5 The Midwifery Council advised HDC that Ms B registered as a midwife in December 2007,completed the First Year Practice Programme in 2008, and was engaged in the RecertificationProgramme at the time the events in this complaint took place.6 Ms C registered in December 2006, completed the First Year Practice Programme in 2007 and wasengaged in the Recertification Programme at the time the events in this complaint took place.7 Ms D registered in 1991 and was engaged in the Recertification Programme. Ms D attended a twodayin-service training on CTG monitoring at the DHB in March 2007. She had been a midwife for 22+years with the DHB but had spent most of that time in a rural primary care unit. When the unit closedin 2003 she was transferred to the delivery suite where she was initially mentored by a senior midwife.4 31 January 2012Names have been removed (except the experts who advised on this case) to protect privacy. Identifyingletters are assigned in alphabetical order and bear no relationship to the person’s actual name.