Baby’s death: Coroner says social risks should have informed discharge from Waikato Hospital six hours after birth

Detailed summary

A baby born to a vulnerable teen mother might have survived had he not been sent home from hospital hours after he was born. The baby, who can only be identified by his first name…

A baby born to a vulnerable teen mother might have survived had he not been sent home from hospital hours after he was born.

The baby, who can only be identified by his first name Remedy, died from severe acute pneumonia, just 34 hours after he was born healthy and well.

The baby and his mother received standard follow-up care in hospital, but a lack of beds meant the young mother’s wish to remain at least a night in hospital could not be met.

According to a coroner’s findings released today, the mother and child’s social situation, including that the mother had no midwifery or antenatal care during pregnancy except a scan at 32 weeks, should have been considered in hospital discharge planning.

A consultant neonatal intensive care specialist, Dr Callum Gately, who provided advice to the coroner, said if Remedy had remained in hospital overnight, his respiratory deterioration would very likely have been identified through routine newborn observations and he likely would have survived.

Coroner Alison Mills said the baby’s death was not the result of any individual failure.

Instead, it highlighted the “systemic under-resourcing and understaffing of our maternity services” and, most significantly, the need for more kaupapa Māori maternity services that could provide culturally appropriate services for vulnerable māmā (mothers).

Coroner Mills said in making a detailed set of recommendations aimed at Health New Zealand Te Whatu Ora Waikato and Oranga Tamariki that there were challenges in addressing an “entrenched and complex systemic problem”, which needed a significant increase in resources, funding and cultural change within institutions.

Remedy was born at Waikato Hospital several years ago. The coroner said it was a normal delivery and he arrived healthy, with a strong cry.

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