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Breastfeeding baby died after ‘distracted’ midwife left room for 25 minutes

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A “distracted” midwife who was “rushing” to complete administrative tasks after a birth left the room for 25 minutes – only to come back and find the baby unresponsive.

She, and the other staff at the hospital fought to revive the newborn, who had just finished breastfeeding, but she died despite being transferred to the Neonatal Intensive Care Unit.

Now, a coroner has criticised midwife Lesa Haynesfor a lack of vigilance and mismanagement of her priorities which resulted in the preventable death of the 30-hour-old baby girl.

An inquest held in 2023 focused on the postpartum care the couple received, in terms of how they were taught to breastfeed the baby and make sure she was able to both breathe and feed.

According to inquest findings, which were released today, the baby was born in 2015 at Palmerston North Hospital, and the parents, who cannot be named, were assisted by Haynes in helping the baby latch before she left the room to complete paperwork and other tasks.

The mother said that at some point during this time, her baby stopped feeding, and she thought this meant she was full and had gone to sleep. Shortly after this, the mother began bleeding and needed to call for a nurse, at which point Haynes returned and noticed that the baby appeared quite still.

Haynes recalls the baby lying on her back, not breathing, with mottled skin and immediately recognised something was wrong and began attempting to resuscitate her.

The baby was intubated and then transferred to Wellington Hospital’s Neonatal Intensive Care Unit. However, it was found that the baby had suffered irreversible brain damage due to a lack of oxygen, and the decision was made to take her off life support.

The cause of death was confirmed as Hypoxic-ischaemic encephalopathy due to neonatal asphyxia during the skin-to-skin contact while feeding the baby.

‘…We didn’t know any better’

The baby’s mother told the inquest that she recalled being surprised at how close the baby needed to be held in order to be fed, and remembers asking Haynes: “Will she be able to breathe?” and being told in response that “The desire to breathe is greater than her desire to feed.”

She didn’t recall any specific instructions on how to keep the baby’s airways clear, and that after the feeding had finished her daughter appeared to be asleep.

The baby’s father said that after the skin-to-skin contact and the feeding began, Haynes left the room a number of times. When she returned and saw that the baby was still, she “immediately grabbed the baby and jumped into action”.

When asked about what he expected in terms of Haynes’ further involvement, he said that they were first-time parents and were in her hands, and it was for her to tell them what to do.

The father said the inquest focused on the breastfeeding, but at the time it didn’t seem like a huge thing because they were told what to expect before Haynes left the room.

“That didn’t seem unusual or alarming to us, we didn’t know any better. Everything was relaxed, casual and there were no details,” he said.

‘I can still see that day in my head’

Haynes accepted that she was absent for about 25 minutes during the second hour of the baby being born, and that she had left the room multiple times in the first hour.

“…it would have been for a couple of minutes to get pain relief but with the amount of work that goes on within that first hour or so, there’s no way I left the room for an extended period of time and would have left them alone,” she said at the inquest.

Haynes explained that once the baby had been born she would keep an eye on the girl’s colour and breathing and checking the placenta and the mother’s perineum. She would also clean up after the birth, position the mother and getting the baby skin to skin.

In terms of breastfeeding she said that she talked about keeping the baby’s face clear, watching the length of her jaw for sucking, what to look for with swallowing, how to make sure that her face was clear.

She said she showed the mother how to put her finger on her breast to keep that away from the baby’s face and then got her to repeat that back to her.

She said she most definitely showed the parents the proper technique for breastfeeding, stating. “I can still see that day in my head, it is very clear, that that’s what I did…I cannot get rid of it”.

After about five minutes she considered that the mother and baby were fine and that the father was capable of watching them, so she left the room to give them some time alone.

The midwife was questioned at the inquest about whether she had an obligation to remain in the room.

“In hindsight, absolutely,” she replied.

Haynes declined to comment further when approached by NZME about today’s findings.

The death was preventable

Coroner Bruce Hesketh said in his findings that Haynes had not provided an acceptable standard of maternity care, that it wasn’t appropriate for her to have left the room, and that the baby’s death was preventable.

“I am satisfied that RM Haynes was rushing to complete her outstanding tasks instead of being vigilant during the very important skin to skin contact and first breastfeed between [the mother] and [the baby].”

“I do not accept it was appropriate in the circumstances of this case to leave the parents alone at the time she did. It was too soon and there had not been sufficient observation of mother and baby during the first breastfeed.”

Coroner Hesketh said that Haynes’ priorities were wrong in leaving the room when she did and that she should have stayed longer to observe.

“I find RM Haynes got distracted when she left the birthing suite and had it not been for the call bell activation and the intervention of [hospital staff], I am satisfied RM Haynes would have been absent for even longer.”

Coroner Hesketh recommended the Te Whatu Ora review the definition of the “Immediate Postnatal period” in its guidelines, and that this period should not encompass just the first one to two hours post birth.

Instead, Coroner Hesketh said this period should be an ongoing assessment that recognised any deviations from normality.

* This story originally appeared in the New Zealand Herald.

Source: RNZ

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Police say person who fired gun at officers still at large

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Police say a person who fired a gun at officers in Napier is still at large.

Eastern District Commander Superintendent Joel Lamb said Police tried to stop a vehicle in the Pirimai Area at about 10pm on Tuesday.

He said someone in the back seat pointed what was presumed to be a firearm at officers pursuing the vehicle.

“Staff have then heard two distinct gunshots as the firearm was discharged.

“Fortunately, neither of our officers were injured, and the patrol vehicle did not sustain any damage.”

He said hours later, the vehicle was seen travelling north on the Waikato Expressway towards Auckland.

Police seized the vehicle at an address in Manurewa, but they had not found the alleged offender.

Lamb said people who lived at the Manurewa address were engaging with Police.

He said Eastern District and Counties Manukau Police were making enquiries.

“Presenting a firearm at a Police officer is a serious escalation that puts our staff and the wider community at risk. This behaviour is entirely unacceptable.

“We are taking this incident extremely seriously and will be pursuing all lines of enquiry to locate the offender and hold them accountable.”

Police asked anyone who witnessed the incident to contact Police on 105 or online using the reference number 261111/3764.

Information could also be provided anonymously via Crime Stoppers on 0800 555 111.

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New Zealand sides named for RLWC finals

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The players tasked with ending Australia’s Rugby League World Cup dominance have been named.

The Kiwis and Kiwi Ferns have announced their squads for this Sunday’s World Cup finals in Brisbane.

Both sides are chasing their first titles since 2008, and both are looking to end their opponents run of three crowns in a row.

“Our Kiwi Ferns have been so dominant in years gone by, and we want to bring dominance back to this jersey, so I think it will be a case of who wants it more,” said co-captain Georgia Hale of the impending clash.

The Kiwis get a major boost for the final as they welcome back Ronaldo Mulitalo after he served a one-match ban for a high tackle against Fiji Bati.

Mulitalo replaces Charnze Nicoll-Klokstad, who moves to the six-man bench, which again includes utility Te Maire Martin, middle forwards Naufahu Whyte, Erin Clark and Xavier Willison plus fullback Keano Kini.

Loose forward Joseph Tapine will make his 30th Test appearance in a familiar pack again, including second-rowers Isaiah Papali’i and Briton Nikora, and props James Fisher-Harris and Moses Leota.

Winger Jamayne Isaako is on the cusp of claiming the New Zealand record for most Test points.

His five goals against Tonga lifted his career points tally to 225 – level with Shaun Johnson – while centre Casey McLean goes into the final with 16 tries in just eight Tests.

Fisher-Harris will again captain the team.

Fullback Ponga said the goal of the group was clear.

“We have high expectations around what we want to achieve, and obviously winning a world Cup is one of them.”

Meanwhile, Ricky Henry has selected a settled side to take on the Jillaroos, led by their lethal centre combination of Stacey Waaka and Mele Hufanga.

Veteran Apii Nicholls takes the number one jersey, Leianne Tufuga and Mackenzie Wiki on the wings.

Henry has stuck with his halves pairing of Chantay Kiria-Ratu and Raecene McGregor with Alexis Tauaneai, Georgia Hale and Otesa Pule up front.

Rounding out the starting pack is Shaniece Monschau, Kaiyah Atai, and Angelina Teakaraanga-Katoa.

“We have been building well throughout the tournament; we understand the Jillaroos side, and will give it our all to make New Zealand proud this weekend,” said Henry.

RLWC Finals:

Kiwi Ferns vs Jillaroos- 6.10pm

Kiwis vs Kangaroos – 9.35pm

Sunday November 15

Suncorp Stadium, Brisbane

Live blog updates on RNZ

Kiwi Ferns:

1. Apii Nicholls 2. Leianne Tufuga 3. Mele Hufanga 4. Stacey Waaka 5. Mackenzie Wiki 6. Chantay Kiria-Ratu 7. Raecene McGregor 8. Alexis Tauaneai 9. Georgia Hale 10. Otesa Pule 11. Shaniece Monschau 12. Kaiyah Atai 13. Angelina Teakaraanga-Katoa.

Interchange: 14. Ashleigh Quinlan 15. Annessa Biddle 16. Shannon Mato 17. Ivana Lauitiiti.

Reserves: 18. Brooke Anderson 19. Zahara Temara 20. Brianna Clark 21. Abigail Roache 22. Tenika Willison.

Kiwis:

1. Kalyn Ponga, 2. Jamayne Isaako, 3. Dane Gagai, 4. Casey McLean, 5. Ronaldo Mulitalo, 6. Kodi Nikorima, 7. Jahrome Hughes, 8. James Fisher-Harris (c), 9. Jeremy Marshall-King, 10. Moses Leota, 11. Isaiah Papali’i, 12. Briton Nikora, 13. Joseph Tapine (v/c).

Interchange: 14. Te Maire Martin, 15. Naufahu Whyte, 16. Erin Clark, 17. Xavier Willison.

Reserves: 18. Keano Kini, 19. Phoenix Crossland, 20. Charnze Nicoll-Klokstad, 21. Scott Sorensen, 22. Leo Thompson.

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Opportunities to mitigate multi-million-dollar RNZ budget blowout likely missed – experts

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Multiple opportunities to identify and mitigate a multi-million-dollar budget blowout at RNZ appear have been missed, according to the former executive director at Audit New Zealand.

The public broadcaster on Monday revealed a near $12 million shock financial loss after a litany of financial blunders, which will now lead to sweeping job cuts.

The $11.8m loss is more than 25 times the $470,000 RNZ had expected to lose over the year to June.

CEO Paul Thompson took responsibility for the result, and said internal reports gave an inaccurate picture of the finances, meaning the scale of the loss only became clear in October.

RNZ’s former chief financial officer Hilary Parker resigned unexpectedly in early October.

The board said it would commission an independent review into what went wrong.

Independent contractor Stephen Walker, who left the Audit Office earlier this year, said the size of the loss was surprising, as was the length of time it took to identify it – months after the financial year ended.

Stephen Walker.
Independent contractor Stephen Walker is a former executive director at Audit New Zealand.

Supplied / OAG

“Probably more of a concern is that they had seemingly been unaware that they were running up a significant deficit until they were in the preparation stage of their annual report in October.”

Walker said public entities typically produced monthly financial reports.

An interim audit also took place before the end of the financial year, he said, but if the organisation hadn’t identified significant losses at that stage, the auditor could also be in the dark.

“It seems that there’s a real weakness in forecasting and budgeting that’s occurred here and that the monthly accounts, when they’re produced, either haven’t identified these significant variances against budget or the magnitude of them really hasn’t come to light until right towards the end of the financial year,” Walker said.

“And really at that point, there’s no opportunity for the chief executive, the leadership team to take, and the board to take, any corrective action because the year has effectively been completed.”

Walker said the “significant miss” was difficult to account for given it was more than 10 percent of RNZ’s total funding.

He said based on RNZ’s annual report, financial complexity didn’t appear to be a factor.

“This $11.8m loss isn’t made up of one particular item … it seems to have been contributed to by a number of separate expense lines running over budget. So I don’t think it’s necessarily to do with complexity.”

Among the errors, RNZ wrongly counted $2m from land sales as income in its budget. Staff costs also came in $3.2m over budget, including $1.4m in redundancy payments.

Professor at Auckland University’s business school Norman Wong said based on media reports the issues identified were “significant and troubling”.

Norman Wong.
Norman Wong.

Supplied / University of Auckland

“But recognising the sale of land as income in their budget is a basic error that one would have expected to have been caught and corrected well before it got to this point.”

With funding reductions at RNZ over the past two years, Walker expected greater scrutiny of financial results.

“Virtually every public entity has had their annual budget reduced. And so you would expect … the leadership team on a monthly basis and board – I’m not sure how frequently the board will consider the information – but you would expect them to be interrogating the results on a regular basis throughout the year,” he said.

Walker said initiating an independent review was the correct course of action and that he’d want to understand what information the leadership team and the board were regularly receiving.

He said he’d “love to say” surprising financial results were rare, but conceded they occured on a semi-frequent basis during his time leading the Audit Office.

“The benefit of independent scrutiny by the Audit Office – and the auditors providing that support to the Auditor General – [is] that the reporting is fairly presented at the end of the year, whether it’s good, bad or ugly.”

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