HDC: Systemic deficiencies in Counties Manukau District Health Board’s post-operative care following Caesarean section

Deputy Commissioner, Rose Wall has made recommendations to a District Health Board (DHB) to improve its obstetrics and gynaecology services following care provided to a woman after the birth of her baby by Caesarean section.

Unfortunately the woman experienced a rare complication of a Caesarean section which was not correctly diagnosed and appropriately treated notwithstanding her presenting symptoms persisted over an extended period without resolution.

Ms Wall noted that systemic deficiencies at Counties Manukau District Health Board (CMDHB) across two visits to the hospital by the woman following her Caesarean section, constituted a failure to provide her with services with reasonable care and skill. Ms Wall therefore found CMDHB in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights.

The woman underwent a Caesarean section in 2019. The baby was born healthy, and she was discharged.

This decision relates to care provided to the woman at the public hospital in the period following the birth of her baby for fluid leaking from her vagina and a breast infection. The woman was discharged without a diagnosis after her first visit to the hospital. After a second visit to the hospital, the woman was told her symptoms were due to expected vaginal discharge after child birth and she was discharged to the care of her community midwife.

The woman’s GP referred her to the gynaecology service around a month later for investigation of her ongoing fluid loss, and, four months after the woman’s Caesarean section, a CT scan was undertaken which showed a fistula between the ureter and the vagina. Corrective surgery was undertaken.

In her report, Ms Wall expressed concern about the care provided by CMDHB, in not undertaking adequate assessment and investigation of the woman’s symptoms, discharging her without appropriate outpatient follow-up in place, and fixing on a diagnosis that was not consistent with the presenting symptoms.

Ms Wall further commented about the differential diagnosis of the woman’s condition by the obstetrics and gynaecology registrars.

“I am critical of the care provided to the woman over two hospital admissions, and the extended time it took CMDHB to reach the correct diagnosis for her presenting symptoms, particularly as they persisted over an extended period without resolution.

“These deficiencies demonstrate missed opportunities to investigate the cause of the woman’s symptoms fully or place her on the correct diagnostic pathway. Where a diagnosis presents as challenging, it is important to ensure that appropriate investigations are completed and differential diagnoses fully explored, or alternatively that there is outpatient follow-up to monitor the resolution of the presenting symptoms or instigate further investigations,” said Ms Wall.

A review of the woman’s care via a Complications Audit and the Maternal Morbidity Meeting was undertaken by CMDHB to identify learnings from this case.

Ms Wall recommended CMDHB provide the woman with a written apology for the deficiencies outlined in the report; implement a clinical pathway for suspected vaginal fistulas to guide clinicians on the appropriate tests and imaging to request, and examinations to undertake; and share an anonymised study of the case with CMDHB obstetrics and gynaecology senior registrars and consultants.