An investigation found that a pregnant woman in her 20s and her stillborn child died after her admission to Palmerston North Hospital’s intensive care unit was delayed.
This incident occurred in February 2022 and was reported by the media later that year. The woman showed signs of severe sepsis upon arriving at the hospital but was not admitted until the early evening, despite staff being aware that she was likely critically ill.
She passed away later that night. Te Whatu Ora Health New Zealand has refused to discuss the circumstances of the woman’s death or release its internal serious adverse event report, which was completed in April 2023.
However, after the media requested it, a report summary was released. The summary included two findings: multiple delays in diagnosing sepsis, identifying the source of infection, and treating it, as well as multiple documentation gaps.
The report also highlighted gaps in communication, cultural responsiveness, and cardiotocography. Five recommendations were listed: review the “escalation pathway” for women in the birthing suite whose condition is deteriorating, provide refresher training on structured communication, ensure staff document maternal observations in the appropriate place, and ensure staff understand and are familiar with local fetal surveillance guidelines.
Sepsis is considered a preventable cause of maternal death, but the Society of Obstetric Medicine of Australia and New Zealand guidelines emphasize the essential nature of prompt treatment.
The internal report was completed in April 2023, well outside the 70 working day periods set by the Health Quality and Safety Commission.
Source: RNZ
