Welcome to 2014.  Best wishes to everyone for a great year and thank you to all those who worked hard through the holiday season to keep our services running.

As you are all aware our Chief Executive Craig Climo will be leaving us this year.

Under Craig’s leadership our organisation has made great progress, and at the same time completed what has been New Zealand’s largest building programme.

We now need to find a leader who can help us all to build on what has been achieved.

The recruitment of a Chief Executive is the most important decision any Board (of Directors) gets to make and we will do everything we can to make sure we get it right.

When choosing a new Chief Executive we need to understand the things that we do very well. But we also need to identify the opportunities that exist to be even better than we are.

To assist with that I have asked the Ministry of Health to organise a team of experienced DHB leaders to carry out of review of our core services.  This will allow us to see where we stand through fresh eyes and clarify the task of the new Chief Executive.

I have asked for the review to be carried out as soon as possible but exact timing will depend on the availability of appropriate team members.  The review should not disrupt your work in any way but if you are engaged by the review team please give them your full cooperation and provide any information they need.

Once we have appointed a recruitment company to work with we expect the process of identifying our new Chief Executive to take at least three months.  The successful candidate will then need to organise their departure from their current employment so it is likely to be at least six months before they are in place here.  In the meantime it is business as usual.

Thank you all for the great work you continue to do.

Bob Simcock

Chair

10 February 2014
Related posts

• Proud to join an organisation committed to caring

 (12HDC00876, 17 December 2013)

Health and Disability Commissioner Anthony Hill today released a report finding a midwife in breach of the Code of Patient Rights for severe departures from the accepted standard of care.

The newly graduated midwife assessed a 31-year-old woman at a birthing centre at 4am, after the woman’s waters broke spontaneously at home and contractions started several hours earlier. It was known to the midwife that the baby was in the posterior position, the woman had experienced difficulties with the birth of her first son, and the woman was anxious and in pain.

Over the following ten and a half hours, the midwife did not adequately assess and monitor the woman and the fetal heart rate, support the woman, or document the care and treatment she provided. Following her assessment at 4am, the midwife administered pethidine to the woman and sent her home against her wishes and when it was not clinically appropriate to do so. When she reassessed the woman at home four hours later, she found the woman to be fully dilated and pushing involuntarily with her contractions. The midwife transferred the woman back to the birthing centre via ambulance. After an hour and a half of active pushing at the birthing centre with no progress, the midwife transferred the woman to the public hospital via ambulance at approximately 1pm.

Mr Hill found that the midwife did not consult a specialist and/or transfer the woman to secondary care in a timely manner, provide adequate handover information to the public hospital staff, or clarify who was responsible for the woman’s ongoing care when the woman was transferred to the public hospital.

The woman’s baby was born at the public hospital at 3pm that afternoon by emergency Caesarean section following a prolonged second stage of labour. Sadly, the baby could not be resuscitated and died shortly after birth. The woman suffered a spontaneous uterine rupture and required emergency surgery, including an abdominal hysterectomy.

In addition to referring the midwife to the Director of Proceedings to determine whether any proceedings should be taken, the Commissioner recommended that the midwife establish a three-year mentoring and continuing education plan with the Midwifery Council of New Zealand and the New Zealand College of Midwives. Mr Hill recommended that the midwife complete that plan before returning to work as a self-employed community-based midwife.

Mr Hill also found the hospital’s obstetric registrar in breach of the Code for failing to adequately assess the woman and for instigating an inappropriate treatment plan. Furthermore, Mr Hill concluded that the woman received poor midwifery care from the public hospital midwives, for which the DHB was found in breach of the Code.

http://www.hdc.org.nz/decisions–case-notes/commissioner’s-decisions/2014/12hdc00876

http://www.hdc.org.nz/decisions–case-notes/case-notes/midwifery-and-obstetric-care-provided-during-labour-(12hdc00876)

Joint statement from Waikato DHB, the New Zealand College of Midwives (NZ COM) and the New Zealand Committee of Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)

Three of the organisations whose members were involved in the care of Linda Barlow on Sunday 25 October 2009 say the circumstances surrounding the case are tragic and resulted from a failure in the system to provide safe maternity care for Mrs Barlow and her baby.

Waikato DHB, the New Zealand College of Midwives (NZCOM) and the New Zealand Committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) say maternity care in New Zealand is generally of a high standard.

Dr Ian Page (RANZCOG), Karen Guilliland (NZCOM) and Corli Roodt (Waikato DHB) said the unfortunate events such as those experienced by Mrs Barlow and her family were rare.

The three made the comments today following the release of the Health and Disability Commissioner’s report into the care provided to Mrs Barlow during the labour and delivery of her son Adam.

“A review of the content and application of policies and procedures for all women receiving primary or secondary maternity care has helped to clarify standards and expectations for all health professionals working in maternity care,” said Ms Guilliland.

“A review of the national referral guidelines resulted in greater clarity in how transfers from primary to secondary care should be made,” she said.

“There have been improvements in the interpretation of  cardiotocography (CTG) by health professionals, as evidenced by the presence of both colleges at a recent meeting on this topic in Melbourne and continuing joint educational activities throughout New Zealand,” said Dr Page.

Mrs Roodt, the Waikato DHB clinical midwife director, said a review of the training and education available to professionals working in maternity care had led to better understanding of the roles and responsibilities in maternity care.

“I’ve seen there are closer relationships between health professionals as a result.”

The three organisations also believe that continuing with multi-disciplinary forums will ensure better communication regarding the care of women and so make it safer.

Consumers of maternity care and health professionals working in this area are receiving the full support of Waikato DHB, NZCOM and RANZCOG.

Related releases

• Waikato DHB accepts HDC findings
• Barlow family response to HDC findings

More information

• Report by the Health and Disability Commissioner
• Women’s Health

Contact:

Mary Anne Gill
Communications Director
Waikato District Health Board
Ph: 07 834 3684
Mobile: 021 705 213

Waikato District Health Board (DHB) has today accepted the findings of the Health and Disability Commissioner, which found the DHB was in breach of the Code of Health and Disability Services Consumers Rights when it cared for Linda Barlow[i] on Sunday 25 October 2009.

Chief operating officer Jan Adams said she had already met with Mrs Barlow and her husband Robert on Thursday 23 January this year to apologise for Waikato DHB’s breach of the Code and for the inadequacies in the care provided by the DHB.

At that meeting she provided the Barlows with a written apology.

“We accept the findings of the Health and Disability Commissioner,” said Mrs Adams.

“In my meeting with Mr and Mrs Barlow, we all took the opportunity to reflect on what happened, what we could learn from it and how we can take those learnings so we can provide quality care for women and their families.”

The Health and Disability Commissioner found there were other breaches of the Code before Mrs Barlow’s arrival at Waikato Hospital.

“While I can’t comment on those I will say Waikato DHB recognises the importance of working in close partnership with all health professionals locally and regionally with the aim of providing the very best care to our patients,” said Mrs Adams.

Waikato DHB has already made a number of changes because of the issues identified in Mrs Barlow’s treatment including the standardised use of the Situation Background Assessment Recommendation Response (SBARR) communication tool and use of transfer of care processes.

As a result of HDC’s recommendations, Waikato DHB will also:

• carry out an audit of compliance with its new Transfer of Care policy, Admission Discharge and Transfer policy, Maternity Transfer of Care procedure, cardiotocography (CTG) credentialing process and Fetal Heart Monitoring Passport and undertake to provide the Health and Disability Commissioner with the outcome of those audits by 5 May 2014.
• focus on CTG interpretation education as per the fetal heart monitoring passport, which includes both face to face and online CTG education.