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Inadequate documentation and standard of care (05HDC18619)
Download Inadequate documentation and standard of care (05HDC18619) (PDF 7Kb)
(05HDC18619, 27 July 2007)
Midwife ~ Assessment ~
Documentation ~ Standard of care ~ Information ~ Stillbirth ~
Rights 4(1), 4(2)
A man complained about the services
provided to his 23-year-old wife by her midwife. In the last month
of her pregnancy, the woman was assessed at a hospital owing to
possible concerns about fetal movement and blood pressure. The
midwife initially had difficulty detecting the fetal heart rate by
cardiotocograph (CTG). The CTG recording was subsequently
interpreted as showing a normal fetal heart rate. The woman's blood
pressure normalised and she was discharged from hospital.
Two days later, the woman was
admitted to hospital for further assessment, with a history of
abdominal pain. A further CTG recording was interpreted as normal
and the woman was discharged home following the administration of
pethidine. Later that day the woman was readmitted in labour and
subsequently gave birth to a stillborn baby boy. The pathology
report noted widespread skin deterioration and it was thought the
baby had died approximately 24 hours prior to the birth.
It was held that the midwife's
clinical documentation was inadequate, included inappropriate
retrospective amendments, and there was no indication that an
appropriate care plan had been developed. The midwife also provided
inadequate information about labour and pain relief options.
Overall, the assessment and care of the woman by the midwife during
the two days before she gave birth was unsatisfactory. In
particular, she failed to take appropriate action in relation to
reports of significant pain, bleeding and reduced fetal movement.
The midwife was held to have breached Rights 4(1) and 4(2).
The matter was referred to the
Director of Proceedings. The Director considered the matter and
issued a disciplinary charge in relation to the
midwife's inadequate monitoring of the woman during labour,
and the considerable additions made by the midwife to the clinical
records after the events.
Link to Health Practitioners
Disciplinary Tribunal decision:
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