A pregnant woman’s ultrasound results were not communicated to her midwife, contributing to a tragic stillbirth two days later, according to findings by Health and Disability Deputy Commissioner Rose Wall. The incident involved Pacific Radiology in Palmerston North and the midwife who referred the woman for the scan. Both were found to have breached the rights of the woman and her unborn baby by failing to ensure timely and effective communication.
Key Findings in the Investigation
The woman, who was slightly more than a week overdue in 2021, underwent a “post-dates” ultrasound scan three days before she was scheduled for an induction of labor. The scan revealed concerning findings, including low amniotic fluid levels and a drop in the baby’s estimated weight. However, the woman was reassured at the clinic that such results were not unusual for her stage of pregnancy.
The radiologist categorized the findings as unexpected but not immediately life-threatening and assumed the report would be sent to the referring midwife automatically. However, due to a coding error in Pacific Radiology’s IT system, the report was never delivered.
The midwife, meanwhile, noted she was “bothered” by the delay in receiving the results but did not follow up, assuming she would be contacted if there was an urgent issue.
Two days later, the woman experienced reduced fetal movements, bleeding, and contractions. Upon arriving at the hospital, medical staff could not detect a fetal heartbeat. The following day, the woman was induced and gave birth to a stillborn baby girl.
Failures in Communication and Responsibility
Deputy Commissioner Wall criticized both the clinic and the midwife for their roles in the breakdown of care.
Pacific Radiology: Wall found that the clinic’s IT system, which allowed reports to be assigned to “empty” codes that prevented delivery, was a critical failure. The radiologist’s decision not to call the midwife directly about the findings compounded the issue. Wall stated that the radiologist’s reliance on assumptions, rather than ensuring direct communication, did not meet professional standards.
The Midwife: Although the midwife assumed she would be notified of any urgent results, Wall emphasized that as the referring practitioner, it was her ultimate responsibility to follow up. The failure to seek out the delayed results directly contributed to the tragic outcome.
Tragic Outcome and Delayed Action
The sequence of missteps culminated in the baby’s death, which could potentially have been prevented with timely intervention. The scan results, if received and acted upon, might have prompted earlier hospitalization and care for the woman.
Wall noted that while the findings were not deemed immediately life-threatening, the delay in addressing the issues led to a critical window of lost time.
Systemic Changes and Remedial Actions
Since the incident, Pacific Radiology has implemented several changes to prevent similar occurrences. These include:
- Updating the IT system to eliminate the possibility of assigning “empty” codes to reports.
- Ensuring that phone calls are made to referring practitioners regarding any urgent or unexpected findings.
The midwife has also undertaken further education and training to enhance her practice, with improvements in her approach to follow-up and communication.
Accountability and Recommendations
Deputy Commissioner Wall recommended that both Pacific Radiology and the midwife issue formal letters of apology to the woman. While acknowledging the steps taken to improve their practices, Wall reiterated that the events had fallen short of the expected standard of care.
Lessons for the Healthcare Sector
This case underscores the critical importance of robust communication protocols and accountability in healthcare. The reliance on automated systems without adequate fail-safes, combined with assumptions about the actions of others, can have devastating consequences.
It also highlights the shared responsibility of all parties in a care pathway—radiologists, midwives, and other practitioners must ensure timely and effective communication, particularly when dealing with urgent or unexpected findings.
A Call for Better Safeguards
While systemic changes have been implemented in the wake of this tragedy, the incident serves as a reminder of the need for continual vigilance in healthcare processes. Ensuring that similar failures are not repeated is essential to protecting the rights and well-being of patients and their families.
This tragic case leaves a lasting impact, not only on the family involved but also on the broader healthcare community, which must strive to learn and improve from such incidents.
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