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Severe hypoglycaemic episode after deteriorating condition missed (07HDC04325)
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(07HDC04325, 13 October 2008)
Maternity Unit ~ District Health Board ~ Hypoglycaemia ~ Rights
4(1), 4(2), 4(5)
Parents complained about the care
provided to their baby at a maternity unit. The baby was born at
full term with no complications, was a good weight for his age and
received satisfactory Apgar scores. He was latching on and
breastfeeding by the time he was transferred from hospital to the
maternity unit. During his stay he was cared for by four midwives.
Two days after his birth, he was noted to have developed jaundice.
His bilirubin levels were tested and he was placed under
phototherapy lights. Although he fed regularly during the day he
became sleepy and uninterested in feeding later that night. By the
next morning his temperature had dropped, he was reluctant to feed,
and he had developed jittery movements - all signs of developing
hypoglycaemia. He was transferred by ambulance to hospital, and
later diagnosed with neonatal hypoglycaemia of unknown cause with
neurological sequelae: epilepsy, developmental delay, behavioural
problems and visual impairment. He is significantly disabled.
It was held that all of the
midwives failed to adequately document the baby's care, and did not
meet professional midwifery standards. This included the
preparation of care plans, documentation of the length and quality
of the baby's feeds and documentation of bowel movements. This lack
of documentation may have affected his continuity of care, as
subtle changes in his feeding pattern and behaviour were not able
to be passed on to subsequent team members caring for him.
Accordingly, each of the midwives breached Right 4(2).
It was also held that the
documentation systems in use at the maternity unit fell below the
standard expected and put patients at risk. Accordingly, the DHB
breached Right 4(1). The inadequate documentation system prevented
effective co-operation among providers to ensure quality and
continuity of services. Accordingly, the DHB breached Right 4(5) of
the Code. The DHB failed to take reasonably practicable steps to
prevent the four midwives from breaching Right 4(2) and was held
vicariously liable for their breaches.
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