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Coroner’s findings provide learning opportunities for DHB

Sue Hayward

Sue Hayward

The tragic deaths of Casey Nathan and her baby son Kymani illustrates how important it is for health professionals across all services to communicate effectively with each other, says Sue Hayward, Waikato District Health Board (DHB) director of nursing and midwifery.

Coroner Gary Evans’ findings into Casey and Kymani’s deaths in May 2012 released 5am today (Saturday 31 January) provide plenty of learning opportunities for the DHB, many of which have already been implemented, she said.

“After Casey and Kymani’s death, we increased the opportunities for our hospital midwives and community-based lead maternity carers to communicate key clinical information with each other in an appropriate way.”

“Waikato DHB considers it of utmost importance that we take any learnings arising from the inquest and apply those across the district.” – Sue Hayward

A world-renowned clinical communication tool called Situation Background Assessment Recommendation Response (SBARR) was already in place in the DHB’s Women’s Health to document telephone conversations between health professionals, such as lead maternity carers, St John, clinicians and midwives.

In a DHB first, the neonatal team implemented the tool for all phone calls in June last year after clinicians considered evidence given at Casey and Kymani’s inquest.

Using SBARR prompts staff to formulate information with the right level of detail.

It was originally used in the military and aviation industries and subsequently developed for healthcare.

Coroner’s findings provide learning opportunities for DHB 2“The SBARR form is completed during or immediately after the telephone conversation with, for example, an LMC, and is filed in a woman’s medical records,” said Mrs Hayward.

The DHB has a Maternity Quality and Safety Programme to lead, develop and implement a key set of policies, procedures and guidelines across the district which also applies to all primary birthing units.

There are 10 primary birthing units in Waikato, four of them owned and operated by the DHB. These units are designed for healthy women who have no complications during pregnancy and are run and staffed by midwives. They do not have facilities for epidural pain relief or caesarean sections.

“We are also in the process of developing an obstetric emergency procedures’ flip chart for use in all primary birthing units,” said Mrs Hayward.

The flip chart sets out key contact numbers, such as the direct phone numbers for the Delivery Suite. It also sets out flow charts relating to a number of obstetric scenarios including birth before arrival to the unit; rapid birth without a midwife; cord prolapse, shoulder dystocia, eclampsia, antepartum haemorrhage, post-partum haemorrhage and a flat baby.

“Privately owned and/or operated primary birthing units have asked whether they can access the flip charts and we are very supportive of that and so we will roll those out across the district.

“We are in the process of substantively reviewing our current flip chart in terms of its content, and the topics covered. The outcome of the review may result in additional topics being added to the flip chart.

“Finally, we’ve taken steps to ensure all lead maternity carers/primary birthing unit staff can easily contact obstetric/neonatal teams in an emergency and we implemented a revised maternity consultation and transfer of care procedure to Waikato Hospital so that lead maternity carers, hospital midwives and medical staff know who is responsible for clinical care at any given time,” said Mrs Hayward.

“None of these measures will bring Casey and Kymani back. For us it is important we learn from what happened and we know our friends and colleagues in other health services feel the same way.

“Our condolences go to Casey and Kymani’s friends and families.

“We thank Mr Evans for his thoughtful consideration of all that happened in May 2012 and he has our assurance that Waikato DHB considers it of utmost importance that we take any learnings arising from the inquest and apply those across the district.”

Read the Ministry of Health response

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General media enquiries
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Ministry statement on Nathan inquest recommendations

The Ministry welcomes the considerations of the coroner in this tragic case and has noted his recommendations, says Dr Don Mackie, Chief Medical Officer, Ministry of Health.

It has been working closely in the past two years with the Midwifery Council of New Zealand and the New Zealand College of Midwives around strengthening the support for graduate midwives, in the light of coronial inquest and Health and Disability Commissioner findings, and the consideration of Parliament’s Health select committee.

The outcome of this has been the development of a strengthened Midwifery First Year of Practice programme, which takes effect from February 1 this year and was announced earlier this week.

This programme will:

  • Make it mandatory for all graduate midwives to undertake the MYFP
  • Give regulatory oversight to the Midwifery Council which includes increased reporting requirements so the Council can assess whether new graduates are practising as expected, or alternatively, that they require additional support.
  • Strengthen mentoring by experienced midwives.

As part of this, the Ministry has also carried out an extensive assessment over the past three years with the sector into the effectiveness and feasibility of placing graduates into hospitals during their first year in practice. The assessment was that this would not be an optimal approach. The Midwifery Council of NZ advises that students are required to complete a minimum of 2,400 hours clinical practice across their undergraduate degree. At least 80% of their final year must include supervised clinical practice.

However the strengthened MFYP programme does recognise that new graduate midwives should be able to easily call upon experienced midwives to attend in complex situations, and has established a system to make this as straightforward as possible.

On the other hand, it is important that in the first year of practice that graduate midwives do experience and gain confidence in operating autonomously as lead maternity carers. The strengthened programme aims to allow this to continue to be the case, while providing the additional support that may be needed from time to time. Structured and career-long learning is a clear expectation for midwives, as with all health professionals.

The Ministry will fully evaluate the implementation of the strengthened MFYP in conjunction with the Midwifery Council, taking account of coroners’ recommendations, both now and in the future.

There is already an established body, the National Maternity Monitoring Group which provides independent oversight of quality and improvements being made in maternity.

The Ministry will be formally responding to the coroner’s findings at a later date.

For further information, contact Kevin McCarthy, senior media advisor, 021 832 459

Kevin McCarthy
Senior Media Advisor
Media Relations
Corporate Services
Ministry of Health
DDI: 04 496 2115
Mobile: 021 832 459

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