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A pregnant woman’s doctor should not have sent her home with abdominal pain and signs of infection, research has found.
The consultant obstetrician and gynecologist breached the woman’s rights when he sent her home despite showing warning symptoms, Health and Disability Deputy Commissioner Rose Wall said.
The woman who was 33 weeks pregnant went to a public hospital in 2021 with abdominal pain and a broken water. She then received treatment and medication before being discharged.
When she went for a scheduled scan four days later, her discharge had turned green and the pain persisted. Instead, she was sent home with an induction booked two weeks later.
She returned the next day when contractions began, but her baby died in utero and she gave birth vaginally.
Wall said it was essential that the woman was discharged with ongoing abdominal pain and green discharge.
“Chorioamnionitis can present subtly and develop rapidly. This would have put the well-being of the fetus at risk,” he said.
“For this reason I would have expected Dr C to arrange for (the woman) to be admitted to the maternity unit for full investigations to be carried out.
“This didn’t happen.”
In the commissioner’s report, the woman’s doctor said she should not have been discharged and should have been sent to the Maternity Unit for further evaluation.
“I still can’t think of any human factors that would be relevant since, although they wouldn’t have excused my mistake, they could have explained why it happened. Their absence is a concern for me, as I would really like to understand why I made such a mistake.” basic,” he said.
“I can’t take it back, but I would like to have more confidence that I won’t make a mistake like that again.”
Wall recommended that you use this report as the basis for a case study presentation in Health NZ Te Whatu Ora, focusing on the breach identified, the decision or actions taken, the outcome and the action that should have been taken.
It also recommended that Health NZ update its obstetric guidance to emphasize the importance of screening patients who may have an infection.
