Charge Detail Summary

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File Number: Mid07/63D
Practitioner: Sharon Louise Robertson
Hearing Start Date:

Hearing End Date:

Hearing Town/City:
Hearing Location:
Charge Characteristics:

Note taking - inadequate/inappropriate (Not Established)


Treatment - care inadequate/inappropriate
(Established)


Communication inadequate/inappropriate
(Established)


Attendance inadequate
(Established)


Additional Orders:


Appeal Order:


Decision:

Full Decision 130Mid0763D.pdf


Appeal Decision:


Precis of Decision:

Charge

Ms Sharon Louise Robertson (the Midwife), registered Midwife of Auckland, formerly of Huntly, was charged with professional misconduct by the Director of Proceedings.  The charge alleged that in particular:

  1. Between 21 July 2004 and 18 November 2004 she failed to take an adequate history from her patient and/or access her previous notes.
     
  2. On or about 9 November 2004 and/or 17 November 2004 when her patient presented reporting a lack of foetal movements, she failed to respond appropriately in that she failed to ensure that:
    a.  A kick chart was commenced;
    b.  and/orA CTG was undertaken and/or interpreted by a registered midwife;
     
  3. When she was notified between midnight 18 November 2004 and 1.00am 19 November 2004 that her patient was in labour, she failed to respond adequately in that she failed to:
    a.  Attend the maternity facility in a timely manner; and/or
    b.  Notify the maternity facility of an anticipated delay in attending; and/or;
    c.  Provide adequate information or handover to the maternity facility.

Finding

The hearing proceeded on the basis of an agreed summary of facts and the Midwife accepted that the circumstances amounted to professional misconduct.  The Tribunal found the Midwife guilty of professional misconduct, but did not find all the particulars were established.

Background

The Midwife became the patient’s Lead Maternity Carer (LMC) on 1 August 2004 and on 17 August 2004, at 27 weeks gestation, conducted her first antenatal check.  The birthing history was discussed briefly, although no notes in that regard were recorded.  The patient was concerned that this particular pregnancy could result in a quick labour.  The patient informed the Midwife that she thought her second birth had been induced because of concerns about decreased foetal movements although she was unsure.  The Midwife advised the patient to record her baby’s movements on the chart in the antenatal book. There was no further discussion as to the patient’s personal/family history, medical history, surgical history, or previous/present obstetric history. 

Antenatal checks occurred regularly for the remainder of the patient’s pregnancy, with no apparent concerns being evident until 10 November 2004.  The patient attended the Midwife for a routine antenatal check on that day, and told her that she had noticed her foetal movements had slowed down. The Midwife documented the foetal heart rate in the patient’s notes.  She discussed with the patient the need to complete the kick chart in her antenatal book.  She did not undertake any testing, for example, a CTG.

On 17 November the patient was concerned and attempted to contact the Midwife, who was attending another patient’s birth at Waikato Hospital.  The patient could not obtain a response and sent a mobile text message to the Midwife.  She received a response stating that the Midwife could see her in one or two days time.  The patient decided to attend Birthcare and was seen by an obstetric nurse who was a registered nurse, but not a midwife.  The nurse tried to contact the Midwife by mobile phone, but was unsuccessful. 

The nurse recorded the foetal heart at 137 beats per minute, and that the heart rate was “strong and regular”, when listened to over a period of five minutes.  The patient was reassured.  The nurse documented this consultation, and left a message for the Midwife on her mobile phone, reporting the patient’s concern about the foetal movements and her actions.  The nurse told the patient she would probably receive a call from the Midwife by way of follow-up.

The Midwife did not ring or visit the patient that day to see if she was all right.  She acknowledged receiving the message, and concluded “all seemed well”.  She accepted at the hearing that she did not know whether a sonic aid or a CTG monitor/trace had been performed; that she made no attempt to clarify whether a CTG had been undertaken, or whether a midwife had been involved.  She had not ensured that a kick chart was being maintained.

The patient began a spontaneous labour at 11.00pm on 18 November 2004.  She rang the Midwife and arranged to meet her at Birthcare.  The patient thought the time when she rang was around midnight.  The Midwife said the time she was contacted was around 1.00am.  The Midwife said that she then contacted the student midwife at 1.10am.  The student midwife held the antenatal notes, which the Midwife wished to collect.  The student midwife said she was contacted around midnight.

After the Midwife received the call from the patient, she went inside her house to wash, change her clothes, have a cup of coffee, and look for her money card as she had just got home from attending another patient’s birth.  Her car was low on petrol and she needed to fill it up on the way to Birthcare (which was 40-50 minutes away from her home).  En route, she called on the student midwife to collect the records.  She arrived there at 1.30am and had a cup of coffee. The Midwife left the student midwife’s house at around 1.40am.  The student midwife’s house was approximately 15 minutes drive from Birthcare.  The Midwife then filled her car with petrol, and proceeded to Birthcare.  She did not arrive until 2.30am.

Prior to arrival, the Midwife did not contact Birthcare, or the patient, to inform them of any anticipated delay or to provide information or handover to the midwife who was on duty.

The midwife on duty at Birthcare was a newly qualified midwife, Ms T.  The patient arrived at Birthcare at about 1.00am, and rang the external bell for entry.  On the basis of information conveyed by the patient, Ms T expected the Midwife to arrive at any moment.

At 1.30am, Ms T recorded a foetal heart rate of 135-137 beats per minutes, and noted that delivery was imminent.  They tried twice to call the Midwife again, but there was no reply.  At 1.45am the patient’s membranes ruptured spontaneously with the delivery of the head.  Ms T saw thick meconium and only a small amount of liquor.  Ms T suctioned the baby’s airway with a catheter (to try and help the baby breathe) while the head was on the perineum. 

Ms T again arranged to telephone the Midwife for help.  Attempts were made to contact various Birthcare midwives and at 2.15pm they managed to contact Ms K, a non-Birthcare midwife. 

At 1.48am Ms T documented cutting the cord and “? FHR < 60” with “(NOT HEARD)” added in the text.  She took the baby and began resuscitation.  The notes record that at 2.15am no foetal heart rate could be recorded and cyanosis was noted.  Ms K arrived at about 2.20am and was told by Ms T that the baby had died.  Ms K also tried to contact the Midwife at 2.26am, but received no answer.  The Midwife arrived at about 2.30 am

The baby’s weight was recorded as 3260 grams with no obvious abnormalities noted. 

Reason for Findings

The Tribunal was not satisfied Particular 1 was established.

The Midwife did not refer to the recorded obstetric history.  However, she did know, as at 17 August that:

  • the patient’s previous babies were small,
  • she had them early,
  • they were low weight,
  • she thought her second delivery had been induced because of concerns about decreased foetal movements, although she was unsure,
  • the births had been quick.

Although the two experts who gave evidence to the Tribunal considered, and indeed the Midwife herself conceded, that there were shortfalls in the obtaining of the history, the Tribunal was not satisfied that there was an outright failure to take an adequate history. 

The Midwife admitted she failed to access the notes relating to the previous births.  However, the Tribunal considered that retrieving the previous notes would be the ideal but not routine practice.  In addition the previous risk factors were noted on the front sheet of the Maternity Notes.  Whilst there may well be instances where it is appropriate to access previous notes because particular risk factors are not clearly understood, the Tribunal did not consider this was such a case.

The Tribunal was not satisfied particular 2(a) was established but found particular 2(b) was established and amounted to professional misconduct.  The Tribunal concluded that:

  • The allegation of not ensuring that a kick chart had been commenced was established, but in the circumstances did not amount to negligence, malpractice or the bringing of discredit to the midwifery profession;
  • The failure to undertake the CTG at the 17 November 2004 appointment and/or have it interpreted by a registered midwife was established, and did amount to negligence, and the bringing of discredit to the midwifery profession.

The Tribunal was satisfied Particular 3 was established and amounted to professional misconduct. The Tribunal considered that even if the time taken was 1½ hours (which was the Midwife’s case), that was quite simply unacceptable.

The Tribunal was satisfied that each of the elements of Particular 3 were established.  The Tribunal considered that the Midwife seriously breached the duties owed to the patient and also placed a vulnerable and inexperienced midwife in a quite unacceptable position.

Penalty

The Midwife was censured and fined $2,080.00.

The Tribunal ordered the following conditions:

  1. That there be supervision/mentoring of the Midwife.  The supervisor/mentor is to be approved by the Midwifery Council, and is to be arranged within six weeks of 17 September 2007, or such other period as the Midwifery Council may determine.  The supervision/mentoring will be for two years, from the date on which the appointment of supervisor is made.  The supervision is to be conducted under the “Framework for Supervision” of the Midwifery Council.
  2. For a period of 12 months from 17 September 2007 the Midwife is to undertake no more than four midwifery cases per month.
  3. The Midwife undertake a New Zealand College of Midwives Midwifery Standards review, within three months of 17 September 2007, or such further time as the College may determine.

The Tribunal recommended to the Midwifery Council that it undertake a recertification audit of the Midwife’s midwifery work.

There was no order for costs, as the Midwife was confirmed to have been legally aided.  If the Midwife had not been legally aided then the Tribunal would have directed costs in the sum of $6,000.00.  The Tribunal directed that details of this decision were to be published in the Newsletter of the Midwifery Council, on the website of the Midwifery Council, in the Midwifery News published by the New Zealand College of Midwives, and on the Tribunal’s website.