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Traumatic stillbirth

Husband shut out of maternity unit

Unresolved maternity issues

First time mother not listened to

Questions about the experience of the backup midwife

Second opinion requested for assessment of wound

Insensitive response to a baby's death

Advocates can assist to refer to HDC, and with investigation findings

Choice of support person denied by midwife

Maternity care rights  

The importance of being listened to

A pregnant woman speaks of how the advocacy process made a very real difference

Concerns following missed swab

A traumatic birth experience



Traumatic stillbirth

Emergency Department ~ Right 1 ~ respect & privacy ~ Right 3 ~ dignity ~ Right 4 ~ appropriate standards ~ ACC claim ~ liver disorder

A woman told an advocate she had been admitted to the emergency department to give birth to a stillborn baby. She was placed near the busy nurses' station where the motion of the nurses passing created the curtains to part, allowing bystanders to see her. When she requested a single room she had been told she was to deliver on to an incontinent sheet or in a bowl. Initially she was told a single room was not available but after she protested one was found.

The consumer went on to say that a specialist had used forceps to assist with the delivery and that while she had consented to the procedure she was unaware of the damage this would cause to the baby's legs. 

The consumer has a liver disorder which means she needs medication to assist with blood clotting. She advised the specialist of this prior to the delivery, but did not receive any medication. The specialist also failed to hook up an IV line prior to pulling the placenta out. The placenta initially did not budge.  Then the consumer felt it coming away following which she bled all over the bed, the floor and the doctor's shoes. The consumer says her partner was traumatised by these events thinking he was losing her. 

The consumer stated she was still traumatised by the birth, when she was visited by another clinician who proceeded to give advice about unplanned pregnancies and immediate contraception. This information was contrary to what the specialist had advised earlier and she felt she was being delivered a "sermon". The consumer was not on a "witch hunt" but felt she needed to raise her concerns including feeling like she was treated as a number, rather than a person with feelings.

After discussing a number of options the consumer chose to write to the providers requesting a written response. At that stage she chose not to ask for a meeting knowing she could do so if she was unhappy with their response. 

The issues the consumer wanted addressed:

1. Why she was  expected to give birth in an environment where her privacy could not be protected

2. Why she did  not receive information about the risks of using forceps 

3. Why forceps were  used when the consumer had been told the baby was positioned at the vaginal entrance.

4. Why medication was not given to assist with clotting. 

5. Why the specialist didn't   insert the drip and let nature take its course.

6. Why there was  no regard for the huge blood loss as a result of the specialist's actions.

7. Why the last clinician who saw the consumer did not recognise the trauma the consumer had been through.

Upon receipt of the written response the consumer contacted the advocate to say she was not happy and wanted to take further action.

The consumer had the following to say about the response:

  • the language they used was defensive, dismissive and patronising 
  • some of the information was conflicting
  • the use of forceps to deliver the baby was disputed
  • there was no acknowledgement of the consumer's liver disorder rather the heavy bleed was put down to a 'retained placenta' 
  • the consumer did not recall an injection being given despite the  provider advising otherwise
  • the consumer felt the explanation about the confrontation about contraceptive options did not address her concerns.

At the consumer's request a meeting was organised with the key personnel involved in her care. 

Prior to the meeting the advocate and consumer met again to discuss how the meeting should proceed. The consumer said she was able to tell her own story, was able to use the Code to illustrate her main concerns and did not want a witch hunt but felt that she needed the right information to support her complaint when she met with the providers. She considered the Code to be the right information.

The consumer's desired outcome was for the provider to realise the learning opportunities from the complaint so others didn't have a similar experience. She also wanted a claim to be lodged with ACC in case there were ongoing repercussions. If a review was to be undertaken of the service the consumer wanted to have an educational role in this. 

Resolution Meeting:

The consumer was able to articulate her concerns so the providers could understand what it was like for her - as a young woman and a mother.

The providers present recognised and acknowledged the consumer's feelings. They also acknowledged that their initial response was inappropriate, expressed remorse and apologised to the consumer.

The agreements reached at the meeting were as follows: 

  • The provider would fill in an ACC claim form for the consumer to access physiotherapy treatment due to problems during the  birth
  • cultural training for all staff regarding blood loss and the impact of this
  • reallocation of space for 'stillbirths' to be addressed with A&E Manager
  • clinicians to address forceps issue and information for consumers

The consumer was very satisfied with the meeting process and the agreements reached.

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Husband shut out of maternity unit

Maternity ~ Right 8 ~ Support person

An advocate received a call from a woman who wanted to complain on behalf of her daughter-in-law. Her daughter-in-law supported the complaint but was unable to make the complaint herself as English was her second language and she had minimal understanding of both verbal and written English. 

The consumer was in her early twenties and was admitted to hospital due to complications of high blood pressure while in early labour. Despite being only able to speak minimal English, hospital staff refused to allow her husband to stay with her and threatened to call security if he did not leave. 

After being provided with information about the Code and the options for making a complaint, the complainant decided her preferred option was to make the complaint directly to the service manager herself. She felt empowered enough to at least start the process without any further advocacy assistance. The advocate obtained the contact details for the service manager and passed them on to the complainant.

The advocate followed up a few days later and was advised by the complainant that she had spoken to the service manager who had agreed that the situation described was not satisfactory and was going to further investigate the matter.

The complainant was happy with the outcome to date and felt she was able to continue the process without advocacy support and requested the advocacy file be closed.

Unresolved maternity issues
DHB ~ maternity care ~ Right 4 ~ appropriate standards ~ Right 6 ~ fully informed
A consumer contacted an advocate regarding an issue with her midwife. Even though there had been a review completed at the time of the initial complaint to the DHB, the consumer felt there were things unresolved and had complained about the midwife to the health and disability advocacy service.
A meeting was arranged so that both parties could have a conversation around what happened with the advocate attending to support the consumer.  Both the midwife and the consumer were able to talk freely about what happened and how the consumer felt.  The midwife was able to explain her process and the amount of time she follows up after a birth.  The consumer was unaware there was a timeframe after a birth but had felt she had just been abandoned by all the staff.   The consumer did not realise that it was in fact the DHB staff that were responsible after the LMC midwife left.
The meeting concluded after an hour and a half and both hugged.  The consumer stated she now understood some of the things that went wrong and could move on as this had consumed her for more than 4 years. There are on-going issues following the birth but with the information from the midwife, the woman is able to follow this pathway and hopefully get further support.
The midwife is also aware that follow-up is important for women to know about. She will make a point of mentioning to new mothers that her contract is to stay only two hours following the birth and then leave the care to the DHB staff.
Everyone felt that the meeting was a good way to move forward  and the consumer said she had felt heard.

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Unresolved maternity issues

DHB ~ Maternity care ~ Right 4 ~ Appropriate standards ~ Right 6 ~ Fully informed

A consumer contacted an advocate regarding an issue with her midwife. Even though there had been a review completed at the time of the initial complaint to the DHB, the consumer felt there were things unresolved and had complained about the midwife to the health and disability advocacy service.

A meeting was arranged so that both parties could have a conversation around what happened, with the advocate attending to support the consumer.

Both the midwife and the consumer were able to talk freely about what happened and how the consumer felt. The midwife was able to explain her process and the amount of time she follows up after a birth. The consumer was unaware there was a timeframe after a birth but had felt she had just been abandoned by all the staff. The consumer did not realise that it was in fact the DHB staff that were responsible after the LMC midwife left.

The meeting concluded after an hour and a half and both hugged. The consumer stated she now understood some of the things that went wrong and could move on as this had consumed her for more than four ears.

There were ongoing issues following the birth but with the information from the midwife, the woman was able to follow this pathway and get further support.

The midwife was also aware that follow-up is important for women to know about. She would make a point of mentioning to new mothers that her contract was to stay only two hours following the birth and then leave the care to the DHB staff.

Everyone felt that the meeting was a good way to move forward  and the consumer said she had felt heard.

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First time mother not listened to

Maternity care ~ Midwife ~ Hospital ~ GP  ~ Right 4 ~ Appropriate standards ~ Pain ~ Unpleasant odour ~ Retained swab ~ Right 5 ~ Effective communication

A consumer, who uses English as a second language, was discharged following a normal delivery with information about caring for her sutures. These were checked by her midwife on days 3 and 5 at which time she told the midwife she had abdominal pain.  She was reassured that it was to be expected. When the pain continued and she noticed an unpleasant odour her husband took her to the hospital where she was examined and sent home with pain relief. 
When the midwife visited 10 days later, the consumer still had abdominal pain. The midwife recommended continuing the pain relief and looking after her hygiene needs better.

Seven days later the consumer's symptoms persisted so she visited her GP who found nothing of note but requested the midwife take a swab to check for infection. Despite no infection showing up the midwife prescribed antibiotics. The symptoms persisted and approximately one month after delivery her GP discovered and removed a gauze swab from the vagina. 

In discussing her complaint with the advocate, the consumer said the health professionals had made her feel like she had no reason to complain, and as a first time mother she did not know whether her symptoms were normal or not. 

The woman wanted an explanation from the providers about how the gauze had been left in her vagina, an apology for the way she had been disrespected as well as compensation for pain and suffering. The advocate advised she could assist with obtaining an explanation and an apology. The compensation matter would need to be explored through other avenues such as ACC.

The consumer did not want to meet with providers and opted instead to have advocacy support with writing her letters. The consumer received responses with apologies for behaviour as well as the inconvenience caused and an offer to assist with her ACC claim.

The consumer was happy with this outcome.

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Questions about the experience of the backup midwife

Maternity ~ Back-up midwife ~ Breech presentation ~  Emergency caesarean section ~ Brain cooling ~ Right 4 ~ Reasonable care & skill

A very distressed consumer rang the Advocacy 0800 number so the advocate arranged to meet her.  At their meeting the consumer told the advocate that having conceived through IVF she went into labour early, at 37 weeks. As her midwife was unavailable she contacted the replacement midwife who advised her to take Panadol for the pain and rest. As the pain intensified the consumer again rang the midwife who instructed her to go to the local Maternity Unit where the baby was monitored but no examination was carried out.

When the consumer's waters broke, as per her care plan, transport was arranged to take her to hospital for a caesarean section. On the way, the midwife said she could see the baby's head and the ambulance driver was instructed to turn around and go back to the unit. Upon arrival the midwife requested another midwife check the consumer and baby, and it was the second midwife who discovered it was the baby's feet and cord that were visible. The consumer was immediately transported to hospital where a team was standing by to do an emergency caesarean section. 

After a traumatic emergency extraction, the consumer was told her baby could have brain damage and/or learning difficulties as following delivery no brain activity could be detected. After "brain cooling" treatment was given, the baby's health and welfare started to improve although the future remains uncertain. The consumer said she and her husband were distressed by the event and had questions about the experience of the replacement midwife.

After considering the options, the consumer decided to send her complaint straight to the Commissioner as she felt that a meeting with her original midwife and the replacement one would not be beneficial due to their close working relationship. The advocate provided her with information and helpful tips for her letter to the Commissioner. 

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Second opinion requested for assessment of wound

DHB ~ Maternity ~ Wound healing ~ Right 4 ~ Continuity ~ Consistent with needs ~ Right 6 ~ Fully informed ~ Right 10 ~ Complaints taken seriously

A consumer contacted the advocacy service about the poor response she was receiving from a hospital maternity service about treatment for a wound that was failing to heal.

The consumer also had issues relating to a lack of information provided by a number of specialists who made further appointments for her rather than discuss a care plan. She also raised concerns that she was not receiving continuity from the midwifery service, as each time she had an appointment she was seen by a different person.

After considering the options, the consumer decided her highest priority was the unhealed wound. She wanted a second opinion from a specialist and requested the advocate support her at a meeting with her GP to discuss her concerns and request a referral to another specialist.

At the meeting with the GP the consumer was able to articulate her concerns and the GP provided the referral to another specialist.

The consumer since advised that her wound was being treated by laser and was healing. Although she had found the other issues annoying she decided not to take any action to address them.

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Insensitive response to a baby's death

DHB ~ Obstetric death ~ Placental abruption ~ Caesarean section ~ Right 4 ~ Appropriate standards ~ Right 6 ~ Fully informed

A woman whose newborn baby died contacted an advocate for support to write to the hospital for a detailed explanation about what happened.

She had been admitted to the maternity unit with heavy bleeding which eventually stopped without intervention. She was concerned at this stage about her unborn baby and asked repeatedly for a caesarean section. Her requests were denied and she felt her concern for the baby was not taken seriously.

Three days later an induction was attempted without success. This was followed by a further attempt the next day that was also unsuccessful.

On day five her membranes were ruptured and it is her belief that it was during this process the main artery of the placenta was damaged without anyone realizing. Early in the morning of day six, she was commenced on IV therapy to promote contractions. Approximately two hours later she experienced a big gush of blood and used the bell to call for help. She was immediately rushed to theatre for an emergency caesarean section. Although she had been reassured everything would be fine she woke from the surgery to be told by the midwife that her baby had died. The woman felt this devastating news was delivered in an insensitive, unprofessional, and disrespectful way.

She had many questions about what had gone wrong. She wanted to know why the first bleed was not followed up; whether it was possible the main artery of the placenta was cut when her waters were broken resulting in the placenta bleeding; and if there was any way the bleed could have been prevented or detected on a scan.

She also wanted to know why she was not offered advice or support during the grieving process. She wanted to meet with those who had provided her care to get answers to her questions and concerns.

The advocate supported the consumer at the meeting where she received responses to all her questions. She was told her baby had died as a result of asphyxiation caused by the abnormal shape of the placenta, which was described as being horse-shoe shaped, with a short cord which had resulted in an abruption. A note was to be put on her file stating that she should be offered a late first trimester scan for any future pregnancy to check the location and shape of the placenta based on what had happened.

At the conclusion of the meeting the woman said she felt her questions had been answered and her concerns addressed. Although coming to terms with the devastating loss of a child was very difficult, having a confirmed cause of death had helped to provide some closure for the grieving parents.

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Advocates can assist to refer to HDC and with investigation findings

Rights 4+5~ Appropriate standards ~ Effective communication ~ DHB~ Maternity care ~ Preventable death ~ Sentinel event

An advocate supported a grieving family to send their complaint to HDC. They had tried to self advocate and were then told about the advocacy service by a family member who worked at a public hospital.

Their complaint was about the preventable death of their first baby, soon after birth. ACC's advisor confirmed this and the DHB dealt with the matter as a sentinel event.

The complaint was investigated by HDC with both a hospital midwife and obstetric registrar being found in breach of the Code (refer to 09HDC01592). At the completion of the investigation, the DHB offered to meet with the family to discuss the HDC findings. The family contacted the advocate who had helped them refer the matter, to seek her assistance at the meeting. Their goal was to achieve some closure on this tragedy so they could move on.

The family met with the advocate to discuss the report and identify the issues that they had concerns about. Each family member had their own concerns they wanted addressed, and these were clarified and written down. A finalised copy of issues to discuss was forwarded by the advocate to the provider in preparation for the meeting. The parents told the advocate that the preparation before the resolution meeting and clarification of issues was a real help to them as they would not have felt able to do this on their own.

Both parents, the maternal grandparents and the advocate were present for the resolution meeting. Three senior DHB staff attended the meeting including two clinical directors. The registrar involved had relocated to another hospital and the midwife resigned following the complaint.

At the meeting the appropriate staff were present with the information required to answer the concerns of the family. As well as answering the individual concerns, the staff expressed sincere apologies for the death of their child. Solutions to provide more effective communication and continuity of care were discussed and input was sought from the family. At the end of the meeting the family acknowledged the role of the advocate. The support and guidance provided through the complaint process and resolution meeting empowered them to clarify their issues and ask the questions that had concerned them. They were happy with the outcome as the process had provided some healing and allowed them to move forward.

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Choice of support person denied by midwife

Right 8 ~ Support person of choice ~ Doula ~ Midwife

A consumer was expecting her second child and early in her pregnancy engaged a local midwife to attend to her maternity needs. The consumer and the midwife enjoyed a good relationship and the consumer was happy with the service provided.

Apart from her husband, the consumer had no family in NZ. As she had been supported by family members during her previous delivery she arranged for the support of a local woman who practices as a 'doula'.(A 'doula' is a non medical person who supports mothers before, during and after childbirth by providing information, physical assistance and emotional support. The provision of support during labour is associated with improved maternal and foetal health and a variety of other benefits.)

In this case, the doula was providing her service on a professional basis and expected to be paid. Although they were also friends, the consumer was happy with this arrangement.

Two weeks prior to the delivery, the consumer advised the midwife that a doula would be supporting her at the birth. The midwife refused to allow the doula inside the delivery suite and said the consumer would have to find another midwife if she insisted on having the doula present. Due to the short amount of time before the birth the consumer was unable to find another midwife so had no choice but to dispense with the doula service. Although the birth went well, the mother was angry and upset with the midwife who had denied her the right to have a support person of her choice present.

The consumer wanted an apology from the midwife and an undertaking that expectant mothers would not be subjected to similar coercion in the future. The consumer also felt that the local midwives would benefit from training on the Code of Rights. With the support of the advocate the consumer wrote to the midwife outlining her concerns and stating what she wanted as an outcome of her complaint.

The consumer received a full apology from the midwife. The midwife also assured her that in future her mothers-to-be would be supported in their choice of a support person. Although the consumer was happy that her concerns about having a support person of the consumer's choice had been taken on board, she was disappointed that her goal of having the advocate provide training was not met as the midwife said the midwives already knew about the Code.

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Maternity Care Rights

Rights 5 & 6 ~ Second opinion ~ Scarred cervix ~ Midwife ~ Obstetrician

A woman contacted the advocacy service after feeling undermined by a midwife and obstetrician. When she became pregnant she was concerned about giving birth because of previous procedures including surgery which had resulted in scarring of her cervix. She did some research of her own and discovered that an elective caesarean was recommended. She approached both her midwife and obstetrician with the results of her research, and was told she would not qualify for a caesarean. She was unhappy at the way the midwife dismissed her research, so she terminated their relationship.

After speaking with the advocate, she was pleased to hear she had the right to a second opinion and to know about the experience of any person providing her care. After considering her options she decided to self advocate and requested a meeting with the midwife and obstetrician to discuss her concerns. The advocate provided information about how to make the meeting most effective, including submitting her questions prior to the meeting to enable those present to be prepared with the answers.

The woman later advised she had taken her partner to the meeting for support. She said the meeting had gone well, with the midwife and obstetrician supplying much needed information. There was acknowledgement from them both that they had not previously had a consumer with the same condition but had provided care for others with similar conditions. They offered to contact some of these women to see if they would be willing to discuss their birthing experiences with her, which was a suggestion she thought was great. They also supplied a list of midwives to choose from as they were concerned she had not replaced the original midwife.

The consumer advised the advocate that following the meeting she felt more at ease, was willing to be supported to try a normal birth, and no longer felt the need for a second opinion. She said the meeting process had worked well. She felt listened to and respected and acknowledged the input of both providers. She appreciated their patience in listening to what she had to say and felt they had accommodated her views.

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The importance of being listened to

A woman contacted an advocate to make a complaint about the midwife who provided her maternity care. Sadly, her baby had died and the woman believed this to be a direct result of the midwife taking no notice of her concerns that something was wrong. The woman felt that had the midwife listened to her, acknowledged her previous birthing experience, acted on comments that this pregnancy felt very different from her other ones and that it didn't feel right and called an obstetrician earlier that her baby would be alive.

Both the obstetrician and midwife provided explanations and an account of what had happened. Despite her grief about the loss of her baby, the woman felt 'lighter' having had the opportunity to tell her story and hear the accounts from the two health professionals involved.

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A pregnant woman speaks of how the advocacy process made a very real difference

I have managed to get to ten weeks with only a few dramas. We saw a heartbeat at six weeks but the baby was too small for its age. Then at seven weeks it had caught up on size but the heartbeat was too slow! By eight weeks everything came right enough so I no longer need such close surveillance.

I ended up being treated better than I ever thought I would be by the provider. At the last appointment we had real respect for each other and I ended up giving a big hug when we were told everything was ok.

I'm sure this wouldn't have happened if advocacy hadn't helped me. I learned a lot from discussing my case with an advocate and from how the advocate handled the meeting. I think that this will be useful to me if I ever have problems with another health provider in the future.

I also have no concerns using the same provider as our relationship has been restored.

The advocate helped me to understand better how the NZ health system works as it is quite different to the one where we came from. In NZ it feels like the patient has to be much more pro-active. I'm very grateful for this as it has made it easier for me to get the information I need.

Advocacy help really did make a difference to the outcome of my situation. Thanks once again.

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Concerns following missed swab

The consumer contacted advocacy for assistance as English is her second language and she needed help with writing a letter to the DHB. She said that four days after the birth of her child, five months earlier, she had passed a swab when passing urine. The midwife sighted the swab and documented the incident in the consumer's obstetric notes and said she would speak with the doctors who had been present at the birth. The midwife later advised the doctors had apologised.

The consumer told the advocate she was still experiencing abdominal pain and abnormal symptoms and was very scared that there was possibly another swab inside her. She decided to write a letter with advocacy assistance. In her letter she expressed her concern and requested a scan to ensure that all of the swabs had been removed.

Shortly after sending her letter she received an appointment for the scan and was very relieved to be told there was no evidence of any other swabs. The hospital wrote an apology and gave a written assurance that they had changed their policy and procedure regarding the removal of swabs. The consumer is now in good health and she and the baby are doing well. She was pleased to have had the support of the advocate when addressing her concerns.

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A traumatic birth experience

A woman underwent a caesarian section, and the attending obstetrician sought and obtained the consumer's permission for students to attend the birth. During the birthing process the obstetrician was engaged in a commentary to the students, although the woman did not recall the content of this. At one point, however, a cell phone rang and the obstetrician answered it, with a nurse holding the phone to his ear.  A joke was made to the effect that his 'banker' was on the phone.

Within minutes of being taken to a nearby recovery area, she was advised that she may have had a surgical swab left inside her.  A bedside x-ray confirmed that this was the case and she was taken back to theatre to have it removed.

Over the next four days she received visits from apologetic staff and the obstetrician who assured her that an investigation had been done to make sure that what happened would not happen again. Upon her return home, she made a complaint and was assured that she would be advised of the outcome of the investigation, and that this process should take a couple of weeks.  After five weeks, having heard nothing, she contacted a local advocate. By this time, an infection of the wound had developed, requiring antibiotics.

In discussing her complaint with the advocate, the woman reported being extremely traumatised by the whole experience, and thought that she may never be able to expose herself to giving birth again. She wrote another letter to the provider asking for a response to each of the following:

  • a review of swab count procedures,
  • concern that the presence of students may have led to carelessness,
  • the laid-back, jokey atmosphere in the theatre,
  • a more disciplined protocol regarding the use of cell phones in theatre,
  • consumers to be advised of the Code of Rights and of the availability of advocacy assistance,
  • where an  event of this nature occurs there should be an offer of counselling, and
  • the length of time it took to deal with the complaint.

All these matters were acknowledged by the provider and appropriate apologies were given. She felt the changes to theatre protocols that were implemented were appropriate, and she was offered counselling.

She was pleased to have received information from the advocate that allowed her to self advocate and knew the advocate was available for support throughout the process. 

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