The Midwifery Council response to HDC Case 18HDC01959

August 2021

The Deputy Health and Disability Commissioner found a midwife (RM) breached Right 4(1) of the Code of Rights by not recognising and identifying that the woman was at risk and no longer suitable to birth at a primary care birthing unit. Consequently, the midwife did not identify that the baby was compromised and, tragically, the baby was stillborn.

Dr Sue Calvert, CEO/ Registrar of Te Tatau o te Whare Kahu, the Midwifery Council, extends her sincere condolences on behalf of the Council to Mrs A and her whānau on the stillbirth of their daughter in 2018. “Our first priority is always the safety of mothers and babies,” Dr Calvert says. “The Council is the regulatory body set up to protect the public by making sure midwives are competent and fit to practise.”

In October 2018, the Midwifery Council received a notification about this case and, in November 2018, the Council undertook a competence review of RM B and found several deficiencies in their performance. Effective from 18 February 2019, the Council required the midwife to undertake a period of supervised practice for a minimum of twelve months. This consisted of monthly case reviews with a supervisor to review her practice and to monitor engagement with education and support to integrate this into their clinical practice.

Additionally, by 31 December 2019, RM B needed to have completed a programme of upskilling education

On completion of each of these components, RM B provided the Council with a reflection that demonstrated the learning undertaken, and the changes made to their practice.

At its meeting in September 2020, the Council considered all the information and noted the midwife had engaged in the prescribed programme of education and made necessary changes and that the programme was fully completed in July 2020, so agreed to take no further action.

“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.”

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.

Released by Te Tatau o te Whare Kahu | Midwifery Council

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