Charge

A Professional Conduct charged that Ms Monique Kapua (the Midwife) was guilty of Professional Misconduct. The particulars of the charge alleged:

1. Between 1 January 2006 and 30 September 2006 the Midwife failed to:
   1. Provide the patient with relevant information about standard midwifery tests and examinations undertaken during pregnancy and/or the reasons for them.
   2. Undertake sufficient standard midwifery tests and examinations. In particular failed to:
      • apart from one occasion, undertake urinalysis for proteinuria and glycosuria; and/or
      • apart from one or two occasions check the patient's blood pressure; and/or
      • arrange or reccommend any blood tests after 13 weeks.
2. Between 22 August 2006 andf 26 September 2006 when the patient was between 28 weeks and 43 weeks pregnant the Midwife failed to provide her with relevant information about:
   1. the risks in prolonged pregnancy;
   2. the induction process and the reasons for induction;
   3. access to and choices of obstetric and secondary care.
3. On or about 11 September 2006 when the patient was about 41 weeks pregnant and the Midwife had last seen her on 6 September 2006 without adequate arrangements for the care of the patient during the Midwife's absence.  In particular, the Midwife failed to:
   1. reccommend to the patient that a consultation with a specialist was warranted and/or make adequate arrangements to ensure that this was done;
   2. provide adequate handover of care of the patient in that the Midwife spoke to another midwife (Midwife A) but failed to;
      • arrange for her to see the patient in the Midwife's absence; and/or
      • provide midwife A with the patient's records; and/or
      • arrange for appropriate assessments for a prolonged pregnancy to be undertaken.
4. On or about 22 September 2006, when the Midwife returned from her period of indefinite leave and the patient was 42 weeks and 4 days pregnant, and knowing that no assessments had taken place since 6 September 2006, the Midwife failed to:
   1. reccommend to the patient that a consultation with a specialist was warranted;
   2. undertake or arrange appropriate assessments for prolonged pregancy including;
      • blood pressure; and/or
      • urinalysis; and/or
      • cardiotocograph trace (CTG).
5. Between 1 January 2006 and 27 September 2006, the Midwife failed to adequately document the care provided.
6. Between 5 Ocotber 2006 and 27 February 2007 the Midwife retrospectively;
   • documented care she provided to the patient without noting that the documentation was retrospective;
   • documented anteantal care that she had not provided to the patient between 1 January 2006 and 5 October 2006
   • inaccurately documented care that she had provided to the patient.

Finding

The Tribunal found the Midwife guilty of professional misconduct.  The Tribunal found that the Midwife’s conduct amounted to malpractice and negligence and in many instances her conduct amounted to acts or omissions that would bring discredit to the midwifery profession.

Background

This case concerned the antenatal care given by the Midwife to the patient between January 2006 and September 2006.  The patient’s son was tragically stillborn.  At the time of his birth the patient had been pregnant for 43 weeks + 2 days.

The prosecution witnesses and the Midwife told very different stories about the antenatal care of the patient.  The Tribunal made credibility findings and they were generally against the Midwife.

The patient and her partner wanted to have a natural home birth at their house some 40 to 50 minutes away from the nearest hospital.  The Midwife is Maori and she practised midwifery, together with traditional Maori birthing practice, had a holistic and natural approach to birth which appealed to the patient.  The Midwife had been recommended to the patient by a friend who spoke highly of her Tikanga Maori.  The patient did want natural care and was attracted to this option and by the Midwife’s calm and confident assurances that with a healthy mama and baby all would be well.

It was an exclusive relationship in that apart from meeting with Ms S, the breastfeeding Kaiwhina there was little contact between the patient and any other midwife.

Reasons for Finding

Particular 1
The Tribunal found this Particular was established.

The Tribunal accepted that the patient and her partner did want a low intervention, natural birth but it also found that the Midwife had an obligation to advocate for more testing (for more good clinical information).  The Midwife admitted she did not do so.  Even if the Midwife had not made this admission the Tribunal would still have found that she did not provide the information or gave it in such a general/casual way that the patient and her partner did not understand the importance of the tests.

The Tribunal also found that she did not offer many tests which should have been carried out such as blood pressure (BP), blood tests and urine analysis and at the end of the pregnancy, CTG and other tests on the baby.

Particular 2
The Tribunal found this Particular was established.

It was of great concern to the Tribunal that as the pregnancy became more prolonged and more out of the ordinary, that no tests were done.  The Tribunal found that the Midwife’s failure to undertake sufficient standard tests or to document why they were not done is a significant breach of the Midwife’s professional obligations.  The Tribunal found that the Midwife failed to arrange or recommend all but a few standard midwifery tests.  The Tribunal did not accept the Midwife’s evidence that the patient declined all these tests.  The Tribunal regarded this failure as a significant breach of the Midwife’s professional obligations.

The Tribunal considered that the time between 38 weeks and delivery is a critical time in any pregnancy.  This was especially true in the patient’s case.  She was at least 40 minutes drive from any medical help and 2 to 3 hours from a secondary hospital.  The Midwife’s evidence showed a real lack of concern about the prolonged nature of the patient’s pregnancy and the risks associated with it. 

The Tribunal accepted some information about induction and access to obstetric care and possibly the risks of prolonged pregnancy was shared at the appointment at 23 September 2006 (when the patient was 42 weeks and 5 days pregnant) but not in a way that made the patient and her partner aware of the real risks and concerns of continuing with a pregnancy that was outside normal limits.  Further, even after the discussion of 23 September, the Midwife had no end point in mind.  She told the Tribunal she did not have a clear plan about “what next” when she left the appointment on 23 September 2006.  She did not plan daily visits or increase her testing. 

The Tribunal found that the information about induction of labour that the Midwife gave to the couple was not balanced (ie, more focus on risks of induction rather than benefits) and did not fully inform them as to the reasons why induction of labour was needed.  The access to an obstetrician seemed to have been discussed, with the Midwife telling the couple they could see an obstetrician but not giving any information about how this could be managed or accessed or how urgent the need for a referral was. 

The Tribunal considered the Midwife’s obligations were to make sure that they knew the risks of prolonged pregnancy, the urgent need for action to end the pregnancy and risks and choices of induction and labour and the need to see an obstetrician.

Particular 3
The Tribunal found this Particular was established.

The Tribunal found the Midwife orally handed over the patient’s care to midwife A on or about 6 September 2006.  The Midwife was very casual in her handover to midwife A.  She told midwife A about the patient but gave her no notes or any effective data.  She did not provide a plan for her care or even ask midwife A to see her.  The Tribunal found it was not an effective handover to leave midwife A her diary and require her to look up hospital records to find details of the scan and blood test.  The Tribunal was satisfied the Midwife left midwife A essentially blind in her management of the patient.

Particular 4
The Tribunal found this Particular was established.

The Tribunal found that by 23 September 2006 the Midwife should have been very concerned about the length of the patient’s pregnancy and the real risks to the patient and the baby that this prolonged pregnancy posed.  A referral to an obstetrician was discussed and the Midwife apparently said that it might be a good idea but did not advise how this could be done, offer to arrange it or advocate for the appointment.  She also seemed unconcerned about the patient’s BP, urinalysis, or CTG and did not advocate for the tests or carry them out.

The Tribunal accepted the patient’s evidence that these tests were not offered or discussed with the patient and her partner.  However, even on the Midwife’s evidence the Tribunal would have found that her failure to proactively advocate for a consultation and undertake the appropriate assessments was a breach of her professional obligations.  The Tribunal found the Midwife was essentially a passive observer of proceedings rather than an advocate for the need to intervene and to seek another opinion.  The Tribunal considered the Midwife did not seem to have recognised that the assessments of blood pressure and urine and additional assessments of the baby’s well being were even more necessary and urgent as the pregnancy became more prolonged.

Particular 5
The Tribunal found this Particular was established.

The notes for the patient’s pregnancy were contained in the clinic maternity notes.  They contained one entry in March 2006.  In October 2006 the Midwife created electronic notes in the Profile system of notes.  The Midwife also made entries in her diary.  The diary notes which record the visit, FHR and a minimum of other information are the only contemporaneous record.  However, the Tribunal considered diary entries do not constitute acceptable notes, nor do the retrospective entries in Profile which were made many months after many of the events. 

The Tribunal considered that accurate notes are the most effective tool in a health professional’s toolbox.  Failure to document is a serious breach of professional obligations and can cause serious harm to the patient.

Particular 6
The Tribunal found this Particular was established.

The Profile notes were entered on 5 October 2006; months after most of the events.  They did not contain any reference to the fact that they were retrospective and the Tribunal considered this should have been clearly noted.

Penalty

The Tribunal cancelled the Midwife’s registration.  She was ordered to pay the sum of $10,000 in costs, $5,000 to be paid to the Midwifery Council of New Zealand and $5,000 to be paid to the Director of Proceedings.

The Tribunal further ordered that in the event the Midwife seeks re-registration, that prior to re-registration, she undergo a specific course of education in order to satisfy the Midwifery Council that she meets the competencies for entry to the Register.

The Tribunal recommended that if the Midwife seeks re-registration, consideration be given to the Midwife practising under supervision for 18 months, following re-registration.