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Hutt Valley DHB has apologized for a series of problems that led to a premature twin suffering brain damage at birth.
At one point, doctors trying to save the baby’s life realized that the oxygen tank was not on.
A report from the Health and Disability Commission on the birth was released today, which found that a radiologist and the DHB had failed in the obstetric and pediatric care of a woman and her identical twins.
During an ultrasound when the woman was seven months pregnant, a radiologist did not notice any signs of twin-to-twin transfusion syndrome, a condition in which twins grow at different rates because they share unequal amounts of the mother’s blood supply. placenta.
Three days later, another obstetrician saw “obvious” evidence of the condition and recommended an urgent C-section.
But the operating room was not prepared for a twin delivery, with only one delivery unit.
The first baby was born pale, flabby and without a heartbeat, and required immediate resuscitation.
It took three attempts to intubate her, before it was discovered that the oxygen tank was not lit.
The baby suffered brain damage during delivery, and developed right hemiplegia, right side paralysis. They didn’t tell her mother until a week later.
“In this meeting they explained [Twin 1’s] injury, however, they did not mention the problems in the theater, but stated that brain hemorrhages were common in[ature] babies, “he told HDC.
The second baby was born in “good condition”.
The Health and Disability Commission says there were multiple failures during delivery, including an intubation tube that was too small, as well as problems with oxygen.
Hutt Valley DHB apologized for the issues, saying it “accepts without reservation the Commissioner for Health and Disability’s finding that we violate the Health and Disability Services Consumer Rights Code by failing to provide services of an appropriate standard.”
“We would like to apologize to the family once again and convey our sincere regret,” Director of Provider Services Joy Farley told 1 NEWS in a statement today.
“No harm to a patient in our care is acceptable and in this case, we recognize that we have failed our patient and family.”
Meanwhile, the initial radiologist now “avoids reporting on twin pregnancies”, saying that he has “reflected on this incident almost daily” and how he could have done better.
Hutt Valley DHB says it has made numerous changes since the case, including updating its equipment, adding mandatory newborn life support training courses, and creating new positions to make midwives available for all caesarean sections.
“As we move into the future, DHB remains focused and committed to monitoring and reviewing recommendations and results,” says Farley.
The woman was in her 20s at the time of birth.
