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Decision 98HDC11321A

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Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Midwife

Complaint   

The Commissioner received a complaint from the consumer and her husband.  The complaint is that the provider, a Midwife:

• failed to detect a loud heart murmur in the consumer's baby at the six-week postnatal check in early August 1997.

• prescribed the combined pill Minulet to the consumer in the knowledge that the consumer was breastfeeding her baby.  The Minulet information sheet states that Minulet should not be given to lactating mothers.

Investigation   

The complaint was received on 23 January 1998 from the consumer and her husband.  An investigation was commenced and information was obtained from:

The Consumer
The Provider / Midwife
The Consumer's General Practitioner

The Commissioner also received advice from a midwife and a paediatric cardiologist.

Outcome of Investigation   

The consumer's baby was born in mid-June 1997 in Hospital under the midwifery care of the provider.  At the six-week postnatal check in early August 1997, the consumer stated that the provider checked the baby's heart and reported that it was fine.  The six weekly check for the baby always includes a developmental assessment and a physical examination of the baby, including all body systems.

In mid-September 1997 when the consumer's baby was 13 weeks old, the consumer took her baby to their general practitioner to be vaccinated and to have her umbilical hernia checked.  The GP did a physical examination of the consumer's baby prior to the vaccination and discovered a heart murmur.  The GP stated that the murmur was an obvious systolic murmur known as a Grade ¾ and quite audible.  The GP then referred the baby to a paediatrician who, after running further tests, diagnosed a ventricular septal defect (VSD) of the heart.

In reviewing the paediatrician's notes of mid-September 1997, the main symptoms recorded, apart from the murmur that might indicate pathology, were the occasional rapid breathing and panting in her sleep.  The specialist reported no problems were noted at birth, no blue or dusky colour observed at that examination, and that the consumer's baby was breast feeding well.

The provider, in her response to the Commissioner, stated that the consumer's baby showed no signs of any abnormality that would indicate a heart defect.  At the six weekly check, the baby was breast feeding well and had increased weight by 560g over the last three weeks and had reached all her required developmental milestones.  The provider added that a Plunket nurse and paediatrician both checked the baby and failed to detect the heart murmur.

The midwife advising the Commissioner stated that:

Ventricular Septal Defect [is] usually asymptomatic until the end of the first month or until the defect is large enough to cause pulmonary oedema.  The first symptoms are rapid respirations, failure to grow and feeding difficulties.  Congestive Right Heart Failure appears between 6 weeks to 2 months of age…The 3 most common manifestations of cardiac defects are cyanosis, detectable heart murmurs and congestive heart failure [symptoms of which include increased pulse and respirations, and perspiration on face and brows].

In summarising the care given by the provider, the Commissioner's midwife advisor reported that the provider's advice and care was appropriate.  The midwife stated:

The murmur was unlikely to have been present at birth so the paediatrician would not have heard it.  It is possible it was present at the 6-week check.  [The provider's] responsibility was to look for the symptoms.

The consumer reported that she observed the provider listen to the baby's heart and ticked a checklist after doing so.  The provider documented her findings in the case notes and in a standardised Check List and this was viewed by the Commissioner.  The midwife advisor noted that:

During the six weeks [the provider] was providing care for [the consumer's] baby… it appears that the heart defect was asymptomatic.  At the six week check, [the baby] has reached all her required developmental milestones.  

The paediatrician asked for advice from a paediatric cardiologist who in early December 1997 wrote a report based on information sent from the paediatrician.  The specialist said that the baby had a poor initial weight gain and showed signs of congestive heart failure, which have settled with medical treatment.  Her weight is running along the 10th percentile, which means that it is in the lower range.

The paediatric cardiologist advised the Commissioner that it is common for these heart murmurs not to be picked up by health professionals and that he has advised midwifery organisations on the importance of training in this area.

In early January 1998, the consumer went to her GP to renew her oral contraceptive prescription.  They discovered then that the consumer was taking Minulet, which is contraindicated in lactating women.  Minulet is a combined oestrogen and progesterone pill and would possibly have inhibited the consumer's milk supply.  The consumer stated that her baby had difficulty suckling because of her increased respiration rate and the reduced milk flow would have compounded her feeding difficulties.  After this discovery, the consumer read the information leaflet on Minulet which said it should not be given to lactating mothers and that small amounts of the hormones have been found in the mothers' milk and the effects on the baby are unknown.

The consumer and her husband then informed the provider of the error and the provider wrote back apologising for the mistake and gave an explanation on why the error occurred.  The provider reported she meant to write "Microlut" but wrote "Minulet" by mistake as this was what the consumer had just told her she had previously been prescribed.  Furthermore the provider stated she did not write "28" which is required for a prescription of Minulet and this omission underlined her intention to write "Microlut".  

The clinical notes on the consumer state "Microlut" but "Minulet" was written on the prescription and this was dispensed.  The dispensing pharmacist then made an error in October 1997 and dispensed another three months' supply without a GP's authorisation.  The Commissioner's midwife advisor stated:

The combined pill did contribute to the poor milk supply and the failure to successfully breast-feed.  [However] the VSD was responsible for [the baby's] condition, not the milk supply.

The consumer believes the wrong contraceptive pill and the failure to detect the murmur both contributed to the baby's poor condition.  It is her view that had these errors not occurred, the baby's condition may not have deteriorated to the extent it did.  The defect will be surgically corrected in 1999.

The paediatric cardiologist advised the Commissioner that the contraceptive Minulet would not have contributed to the baby's heart condition and health status.  The paediatric cardiologist further stated that diagnosing the baby's heart condition at six weeks as opposed to three months would not have altered the course of the illness or influenced the medical management of her condition.

Code of Health and Disability Services Consumers' Rights   

RIGHT 4: Right to Services of an Appropriate Standard

3) Every consumer has the right to have services provided in a manner consistent with his or her needs.
4) Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.

Opinion: No Breach    

Right 4(3)

In my opinion the provider did not breach Right 4(3) of the Code of Health and Disability Services Consumers' Rights.  The provider listened to the baby's heart sounds and did not hear the heart murmur at the six-week check.  While it would have been ideal for the heart murmur to be detected, there is insufficient evidence to suggest that the provider should have been able to hear abnormal sounds at this time.  Furthermore, the ventricular septal defect was correctly diagnosed at three months and medical treatment commenced.

Opinion: Breach

Right 4(4)

In my opinion the provider breached Right 4(4) of the Code of Health and Disability Services Consumers' Rights.  The provider, by her own admission, made an error in writing a prescription for an oral contraceptive, which is contra-indicated for lactating women.  Additionally the prescription included a second three-month supply and resulted in a repeat being dispensed by the pharmacist.  I note the pharmacist has accepted that an additional three months' supply should not have been dispensed.

Actions   

I recommend that the provider provide a written apology for her breach of the Code of Rights to the consumer.  The apology should be sent to this Office within one month.  The Commissioner will then forward it to the consumer and a copy will remain on the investigation file.  

A copy of this report will be sent to the New Zealand Nursing Council.  

In response to my provisional opinion, the provider wrote an apology to the consumer and her husband and the file has been closed.