Care of woman with ongoing complications following miscarriage

A woman became pregnant but, sadly, an ultrasound confirmed a non-viable pregnancy. The woman presented to a public hospital with pelvic pain and vaginal
bleeding.

She went on to experience ongoing complications that did not subside for eight months. During this time, the woman was admitted to hospital at least six times — four were acute visits, and she received care from no fewer than seven individual providers.

During the course of her care, the woman experienced an infection, and required two blood transfusions. She continued to bleed, and the cause of the bleeding was
not assessed adequately until eventually she required activation of the major haemorrhage protocol and admission to ICU.

The Commissioner was critical that over a prolonged period of time, many staff did not assess the cause of the woman’s ongoing bleeding adequately, and did not treat it effectively until she became significantly unwell and required ICU care.

The woman was not provided services with reasonable care and skill, and the DHB was found to have breached Right 4(1).

Individual criticism of three obstetrician/gynaecologists was made for having not ordered ultrasounds or checked the woman’s haemoglobin levels at various
appointments.

It was recommended that the DHB provide a copy of its audit plan for the previous year reflecting the changes made to its policy on miscarriages. It was also recommended that the DHB provide a written apology to the woman.