The cause of death of a baby at Botany Downs Maternity Unit in 2017 remains unknown, the Coroners Court has determined.
Evana-Jade Anarihi Iro-Tulikaki, aged about 8 hours and 25 minutes, died on February 27, 2017 at Middlemore Hospital, Auckland, of “unascertained causes”.
Evana-Jade was born at the Botany Downs Maternity Unit on February 27, 2017 at about 4.15am, under the supervision of a Lead Maternity Carer (LMC). After her birth, Evana-Jade was placed on her mother’s chest in the birthing pool.
Her mother remained in the birthing pool for about 20 minutes with Evana-Jade resting on her chest, with her chest down in the water.
The mother then moved onto a bed to deliver the placenta, keeping Evana-Jade on her chest.
The LMC put a baby hat onto Evana-Jade and got a warm towel for her and a blanket to put over both mother and baby.
The midwife said she continued to assess Evana-Jade’s position and colour and did not notice anything that caused her any concern during this time.
As there were no concerns about either mother or baby, the LMC left the room briefly at around 5am to prepare toast and milo for Evana-Jade’s parents.
When she returned, all appeared well, and she left the room again between about 5.14am and 5.19am to complete some paperwork.
Evana-Jade’s parents said they thought she sounded wheezy during this time and advised the LMC of this when she re-entered the room.
The LMC noticed that Evana-Jade’s skin tone had dramatically paled and that she appeared to be having trouble breathing.
Staff at the Maternity Unit commenced resuscitation procedures and an ambulance was called at around 5.33am via an 0800 professional healthcare line. At 5.55am, the LMC called 111 as no ambulance had arrived.
At about 6.04am, a neonatal team arrived by ambulance and transported Evana-Jade to Middlemore Hospital, where she was treated in the Emergency Department before being transferred to the Neonatal Intensive Care Unit in a critical condition.
At around midday, Evana-Jade’s parents were advised that further resuscitation efforts were futile. She died at 12.40pm.
Counties Manukau Health (CMH) undertook a comprehensive review into the circumstances leading to Evana-Jade’s death.
Their report noted that Ministry of Health (MoH) Guidelines were not followed in that the mother and Evana-Jade were left without medical supervision several times in the first hour after birth.
The CMH Report also noted that the information displayed at the Maternity Unit for calling St John Ambulance Service advised calling the professional 0800 number rather than 111.
Coroner Erin Woolley said in her report, “The outcome in this case is utterly tragic, and, unfortunately, despite a thorough investigation into Evana-Jade’s death, there is no one clear answer about what medically caused her to die. The investigation has, however, identified some issues that could have contributed to this outcome.”
She found the following contributed – the initial temperature of the bath water, at 38 degrees Celsius, was too hot and that Evana-Jade may have got cold in the bath after birth.
She also found mother and baby were left alone in the first hour after birth while skin to skin contrary to the MoH Guidelines.
“There were delays in calling an ambulance and, when called, a non-urgent 0800 number was called rather than 111. Further, it was not clearly conveyed to St John that there was a life-threatening emergency situation.”