A first-time mother lost her newborn baby after the midwife failed to record her severe morning sickness and weight loss which restricted her baby's growth.

The investigation into the incident by Deputy Health and Disability Commissioner Rose Wall​, found the Bay of Plenty District Health board in breach of the Code of Health and Disability Services Consumers' Rights for a number of failures in the care of a woman and her baby.

The woman, who isn't named, was in her 20s and had a difficult pregnancy in 2017.

She lost weight and required multiple hospital admissions for severe morning sickness and her baby's growth was restricted, the report says.

However, her midwife did not record the woman's weight or fundal height at every antenatal assessment.

It was found that while the midwife continued to review the woman while she was with the obstetrics team, she did not document when she formally handed over care to the team.

When the woman was under the care of the DHB, there was no formal management plan and no clear guidelines for staff on the management of severe morning sickness and malnutrition.

When the baby was born, she was recognised as "at-risk" owing to her low birth weight.

However, the baby's blood glucose level was not monitored in a timely manner, and a paediatric review was not requested.

In addition, she was administered a higher-than-recommended dose of phenobarbitone, a barbiturate used to prevent seizures.

The baby girl's condition deteriorated, and she was admitted to the neonatal intensive care unit, where she died.

The woman's whānau says in the report the baby was never given an opportunity to grow and mature.

'They say that time heals all wounds, but I can say that the whānau will never ‘get over' the passing of [their baby].”

The whānau at no point wanted to lay blame on individuals and acknowledged there were some amazing health professionals involved.

'The whānau would like to reiterate that it was a lack of appropriate resources and procedures that causes this, and, we as a whānau would like assurance that this will not be the case for any future pregnant mothers who find themselves in that position.”

Wall is critical that the transfer from the midwife to the obstetrics team was not clear, and a formal management plan was not documented.

Also, the departure from the DHB's policy on paediatric review and blood glucose monitoring.

Wall criticises that the dose of phenobarbitone administered to the baby was not consistent with the guidelines.

And that the opportunity was missed to seek specialist advice about a baby, who was significantly small for gestational age.

"Although it is not possible to determine whether the outcome could have been changed, I am critical that the DHB did not ensure that staff were supported with adequate systems to guide and deliver appropriate care, including a requirement to develop comprehensive management plans in such complex cases,” Wall says.

She recommends that the DHB provide an update on implementation of the nausea and vomiting in pregnancy guidelines.

Wall also recommends the DHB consider developing guidelines for when consultation with a multidisciplinary team, and development of a formal plan, is required for a ‘significantly small for gestational age' baby, or a woman with severe symptoms.

And for when a woman with a small for gestational age fetus requires referral to a fetal medical specialist or a larger centre.

Wall recommends that the midwife provide an update on the order concerning competence issued to her by the Midwifery Council of New Zealand.

-Stuff