Deputy Health and Disability Commissioner Rose Wall today released a report finding Waikato District Health Board in
breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for the care provided to a pregnant
The woman, who was 28 weeks pregnant, presented to the public hospital with abdominal pain. Assessments by the obstetric
and general surgical teams had not established a cause for the pain before the woman collapsed 17 hours later and was
found to have a ruptured uterus. The baby initially survived, but died a month later as a result of birth hypoxia.
Ms Wall noted that the rupture of an unscarred uterus in a non-labouring woman is extremely rare and, prior to the
woman’s collapse, it was not a diagnosis that would have been considered or made by many clinicians in the
circumstances. However, the Deputy Commissioner criticised Waikato DHB for a number of deficiencies in the Obstetric and
General Surgery reviews. These included missed opportunities for increased senior oversight and inadequate documentation
of some reviews.
Ms Wall also considered that a lack of effective communication and co-ordination between the Obstetrics and General
Surgery teams contributed to a delay in appropriate radiological assessment.
Ms Wall recommended that Waikato DHB report on the action points identified in its Serious Incident Review Report;
provide evidence of recent staff training on co-ordination of care, escalation of care, and documentation; use the
report as a basis for staff training; and report back on its implementation of the New Zealand National Maternity Early
Warning system (MEWS). She also recommended that the DHB apologise to the woman and her family. These recommendations
have been complied with.
The full report for case 17HDC00453 is available on the HDC website.