The parents of a baby who died after a disastrous delivery say they forgive the midwife whose mistakes contributed to their son's death.
Linda and Robert Barlow's baby, named Adam, died at Waikato Hospital in October 2009. Linda also suffer a stroke and a heart attack during the birth, and was told she would not be able to carry children again.
In findings released today, Coroner Gordon Matenga found midwife Jennifer Rowan's failure to notice Linda's labour was not proceeding normally contributed to Adam's death.
Speaking to TV ONE's Close Up tonight Linda and Robert said they forgive Rowan, but are disappointed in her actions.
"Jen, we forgive what you did to me and my family on the 25th of October 2009, but we're very disappointed that you haven't take accountability, responsibility for your actions that led to the death of my son Adam and my injuries," Linda said.
"I didn't receive midwifery care on that day and I was left to labour on my own in pain and I just want to know where your humanity was."
Robert said his memories of Adam were too "precious" for any ill-feelings towards Rowan to get in the way.
The Barlows requested a coroner investigate their son's death after reading medical notes indicating her son had shown signs of life, such as moving feet and hands, despite him being declared as a stillborn.
Matenga concluded Adam died of intrapartum asphyxia, an impairment of the delivery of oxygen to the brain due to a prolonged labour. He said failures on Rowan's part contributed to the baby's death.
The Coroner agreed with evidence from the Barlows' lawyer Kate Davenport that Adam died due to Rowan's failure to recognise that the progress of labour was not normal and to convey urgency to DHB staff after transferring from the River Ridge East Birth Centre in Hamilton to Waikato Hospital.
He said after Linda arrived at the hospital, there was uncertainty as to who was responsible for providing midwifery care, which led to no one taking responsibility for her labour.
Matenga said the confusion arose from staff failing to follow guidelines.
Other factors were Rowan and DHB staff failing to make efforts to speed up Adam's delivery and not interpreting the CTG trace, which records the foetal heartbeat.
Rowan, who was aged 23 at the time and just seven months out of training, said through her lawyer she regrets any part she may have played in the tragic outcome.
But she said she does not accept her training and degree of experience contributed to it. She is still a practising midwife, currently on maternity leave.
Matenga recommended changes to midwifery training and Ministry of Health guidelines, but the Barlows say drastic changes are needed to prevent other families going through what they did.
They believe graduate midwives should spend two years working as "juniors" in hospitals, before they can become lead maternity carers.
"It's scary that someone can come out of a training programme, midwifery training, straight to be an independent midwife in the community and be responsible for two lives - the mother and the baby," Linda told ONE News.
Matenga said evidence supplied by Rowan was "self serving" and there were gaps in her documentation.
One example was her claim that she listened to the foetal heartbeat on more occasions than what was recorded in her clinical notes, which Linda and her husband Robert said was not the case.
"There were clear gaps in her documentation and she was trying to piece together the clinical picture from an incomplete record," Matenga said.
"Accordingly, my approach to Jennifer Rowan's evidence is that where her evidence ... is in conflict with evidence given by other witnesses, Jennifer Rowan's evidence will be given very little weight."
Matenga recommended the following amendments to the Ministry of Heath's referral guidelines for midwives:
- Clarify the definition of the commencement of second stage of labour to remove ambiguity.
- Provide a process for the transfer of clinical responsibility for midwifery care from the LMC (lead maternity carer) to secondary midwifery care that involves a conversation between the LMC, the secondary midwife, the woman concerned and any specialist involved, to determine that the transfer of midwifery care is appropriate and acceptable, and determine the respective roles and responsibilities.
- Emphasis that referral guidelines should be followed in most cases.
He also recommended that the Waikato District Health Board require its obstetrics registrars consult with the supervising specialist on every woman who has transferred from primary care.
He recommended the Midwifery Council of New Zealand review midwifery training to ensure training is consistent with referral guidelines, making the Midwifery First Year of Practice programme compulsory, and changing the mentoring role in the programme to a supervising role.