A baby girl born at Botany Downs Maternity Unit in Auckland, died less than 12 hours after her birth. (Picture file)
The cause of death of an eight-hour-old baby will remain a mystery after a coroner ruled the cause to be “undetermined”.
Evana-Jade Iro-Tulikaki died in February 2017 at Auckland’s Middlemore Hospital. She was born at Botany Downs Maternity Unit eight hours and 25 minutes earlier.
Coroner Erin Woolley said immediately after birth, Iro-Tulikaki was placed on her mum’s chest in the birthing pool for 20 minutes, before moving to the bed 45 minutes after the birth while the lead maternity carer (LMC) left the room to make the new parents toast.
The LMC came back and briefly left again to complete paperwork, during this time the parents said their daughter sounded a bit wheezy and informed the LMC.
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The LMC noticed Iro-Tulikaki was having trouble breathing, staff began resuscitation procedures and an ambulance was called at 5.33am through a professional help care line.
Over 20 minutes later an ambulance hadn’t arrived, so the LMC called 111. A team arrived at 6.04am and Iro-Tulikaki was taken to Middlemore Hospital’s neonatal intensive care unit. She died at 12.40pm that day.
Counties Manukau Health (CMH) undertook a review into the circumstances of Iro-Tulikaki’s death and noted Ministry of Health guidelines weren’t followed, as mum and baby were left alone several times in the first hour of birth.
The report noted using the non-urgent phone number to call for an ambulance potentially delayed the transfer to hospital by up to 26 minutes.
“There was a miscommunication regarding the type of ambulance required. This led to the wrong type being sent, which was designed to provide patient transfer, not medical treatment,” the report stated.
Woolley said the situation was “utterly tragic” and despite a thorough investigation there was no clear answer about what caused Iro-Tulikaki’s death.
However, Woolley said there were factors which contributed to it – this included the initial temperature of the bath water, being too hot at 38 degrees, Iro-Tulikaki potentially later getting cold in the bath, mother and baby being left alone in the first hour and delays in an ambulance arriving.
Following the incident, CMH advised Woolley they had spoken to the LMC about what happened and flowcharts about what to do in an emergency were now displayed in all primary birthing units.
“The LMC identified changes in her practice were required, in particular with the advice she gives to parents about recognizing a baby becoming unwell and ensuring she closely watches in the first hour following birth,” Woolley said.
“I recommend for any water birth she is LMC at, she ensures the temperature of the bath water is never warmer than 37.5.
“In emergency situations she needs to seek help from other midwives or emergency services as quickly as possible.”
CMH offered their condolences to Iro-Tulikaki’s whānau and said since her death it had introduced a neonatal early warning score which showed an escalation pathway for newborns of concern.