A baby was harmed by a difficult birth at Waikato Hospital following delays caused in part by staff failing to notice heart-rate abnormalities.
The infant, who has been left with developmental delays, is one of the statistics in the annual tallying-up of patient disasters at our public hospitals.
The Health Quality and Safety Commission said there were 360 reported serious or sentinel adverse events in the year to July 31, in which 91 patients died, although not necessarily from the event.
In 2010/11, there were 370 cases, including 86 deaths. "Serious" means an event that led to significant extra treatment, while "sentinel" means life-threatening, fatal, or the cause of major loss of function.
The Waikato District Health Board report on its mistakes and other events, such as an inpatient's suicide, says that in the baby's case, the failure to notice problems in the fetal heart rate was one of several factors that contributed to delays in the baby's delivery by caesarean section. Others were having too few staff for a delivery suite that was full that day, and delays in putting in an epidural.
The mother was earlier in labour in the hospital's assessment unit and had a belt around her tummy to allow the baby's heart rate, in relation to contractions, to be monitored by a cardiotocograph (CTG) recording machine.
Chief medical adviser Dr Tom Watson said staff misinterpreted the CTG trace.
When the first serious and sentinel event reports were made public in 2008, they disclosed that eight babies had died in three years in cases which involved fetal or heart-rate monitoring problems. Hutt Valley and Canterbury DHBs had given staff training, only to have another baby die in similar circumstances.
The Waikato DHB also implemented a training programme in reading and understanding fetal heartbeat monitoring, as well as other changes to reduce delivery delays for babies in distress.
Dr Watson said that previously the staff in the assessment area, where the woman was in labour, weren't as highly trained in fetal heart monitoring as others in the women's health unit.
Midwifery Council chairwoman Dr Judith McAara-Couper said she wasn't aware of any problems with midwives' use of CTG monitoring. Most midwives had completed training in CTG monitoring in the past five years and it was also part of the university midwifery education.
* Breathing tube accidentally displaced during trauma patient's CT scan. Causes fatal additional brain injury due to lack of oxygen.
* Woman dies following multiple re-operations needed because of injury to bowel during gynaecological surgery.
* "Clinic outcome" form lost, so no follow-up appointment. Patient goes blind in their only seeing eye.
* False-negative laboratory test result. Death of a fetus.
Counties Manukau DHB
* Delay in recognising a ruptured uterus in a pregnant woman who had previously had a caesarean delivery. Baby stillborn. Woman loses her uterus.
* Lung CT scan findings "significant", but necessary follow-up appointment not arranged. Patient turned up again two years later. Cancer diagnosed. Patient died.
* Seriousness of the condition of a baby with history of vomiting and diarrhoea not recognised. Discharged home. Brought back next day. Died.
* Caesarean section for fetal distress. Baby died at birth.
* Patient, 83, developed blood infection and subsequently died. Intravenous leur entry point likely cause of infection.