The Midwifery Council response to HDC Case 19HDC01789


August 2021


The Deputy Health and Disability Commissioner found a midwife (RM) breached Right 4(1) of the Code of Rights by not recognising cumulatively that the woman showed signs of impaired health, which meant that a referral to secondary care was warranted but not done.

The Deputy Commissioner was critical that the midwife did not perform a urinalysis at each visit, did not take a blood test to monitor the woman for pre-eclampsia, did not measure the fundal height in centimetres, and did not monitor the fetal growth adequately. The Deputy Commissioner was also critical that the midwife did not recommend an assessment of the woman in person when this was warranted.

In addition, the Deputy Commissioner was critical that the midwife did not maintain accurate records of the antenatal care she provided, and that her arrangement to provide remote oversight was not suitable to detect and respond to the issues that arose as the woman’s pregnancy progressed.

The Council was notified of this complaint in October 2019. The Council convened in early November 2019 and decided that the midwife should undertake a Competence Review as soon as possible. The review took place in early December. The Competence Review report was received in early 2020 and the Council agreed, based on the findings, to take no further action. The reviewer acknowledged the Midwife’s positive response and recommended that she improves her documentation. The Midwife no longer accepts booking from women who live outside her district and attended further education on the Growth Assessment Protocol.

The Deputy Commissioner has recommended that the midwife undertake training on pre-eclampsia and documentation; provide HDC with a reflection on the training undertaken on the Growth Assessment Protocol; and provide a written apology to the woman and her whānau. The Council will consider the Deputy Commissioner’s Opinion and decide whether any further action is required in order to protect the safety of the public.

“Safety is paramount,” Dr Calvert says. “The Council expects all midwives to practise in a way that is clinically and culturally safe. All midwives need to ensure that no act or omission places wāhine and whānau at risk.”

Dr Calvert says: “Our first priority is always the safety of mothers and babies as the Council is the regulatory body set up to protect the public by making sure midwives are competent and fit to practise.”

Released by the Midwifery Council
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