![]() Information gathered during investigation Independent expert advice from midwife Mrs Chris Stanbridge, obstetrician Dr Peter Dukes, and anaesthetist Dr Malcolm Futter.Reports from midwife Mrs F and the Clinical Manager of the provincial hospital.The provincial hospital's Sentinel Event Investigation Report. ![]() The Commissioner commenced an investigation on 7 April. The delay in assembling the full operating theatre team to perform an emergency Caesarean section and the subsequent delay in delivering twin two.The absence of a paediatrician and anaesthetist at the birth of twin one.The non-placement of epidural anaesthetic following request at about 10.45pm.The lack of CTG monitoring after 10.30pm on 20 March.The Commissioner reviewed the Report and decided to investigate the actions of midwife Mrs C, obstetrician Dr D, and anaesthetist Dr E in relation to the following issues: They forwarded a complaint to the Health and Disability Commissioner, which was received on 12 August. Although the Report identified a number of deficiencies and recommendations about maternity services, Ms A and Mr B disputed some aspects of its findings. The hospital conducted a Sentinel Event Investigation and its report (the Report) was provided to Ms A and Mr B on 17 July. Ms A gave birth to twins at the hospital on 20/21 March. On 8 April Ms A and Mr B made a complaint to a provincial hospital. A Provincial HospitalĪ Report by the Health and Disability Commissioner Parties involvedÄr G Obstetrician and Gynaecologist / Advisor to ACC Complaint Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name. Names have been removed to protect privacy.
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