A midwife has admitted to having a rocky relationship with a woman whose premature baby died in her care.
The health worker has been censured for failing to fully assess the patient, which would have shown she was in labour.
The mother complained to Health and Disability Commissioner Anthony Hill, who said there was a "history" between the midwife and the woman which "may have led to some tension in their interactions".
The midwife was more upfront, telling an inquiry her relationship with the woman "impacted significantly" on the care she provided.
The commissioner's office examined the case after the baby died in 2013 following his delivery at 26 weeks' gestation.
It was not known where it happened, as that information was withheld, but a report released today said it was rural and remote, and only two midwifes cover the entire area.
The investigation centred on why the midwife did not carry out a vaginal examination or ask the patient if she wanted one. Instead, the carer felt the woman had a urinary tract infection.
After being sent home, she was taken into hospital by ambulance and her baby was delivered, weighing 930 grams.
He was initially stable but died in the neonatal intensive care unit after developing a range of problems, including bowel obstruction and cardiac issues. He was also diagnosed with brain haemorrhages.
Mr Hill said the baby died "owing to complications associated with his extreme prematurity".
However, he said the midwife did not do enough to care for the woman and gave "insufficient consideration to the possibility that [the patient] was in labour".
The Midwifery Council looked at whether the midwife was still fit to to her job and found she was. However, it ordered her to do extra training and practise under supervision.
Claims and counter-claims
The report went into detail about the relationship between the patient and the midwife and included many claims and counter-claims.
The woman was pregnant with her fourth child and had a self-employed, community-based midwife as her lead maternity carer.
However, that carer was unavailable when the woman needed her, and instead the midwife who had been faulted was on call.
Following the birth of her third child, the patient had a made a complaint about care provided by that midwife and said she did not want her involved in her care during her latest pregnancy.
When the patient arrived at the local maternity unit for an assessment, the midwife said the woman and her partner's "mannerism towards her was very antagonistic and as a consequence, information was not forthcoming".
The patient told investigators the midwife was rude to her as she left the unit, and said she was "non communicative and hostile". However, the midwife denied that.
A support worker who was also in the maternity unit said there was clearly "tension" between pair but that the midwife was "extremely professional throughout the entire consultation".
It was claimed the patient asked for a drink when she and the midwife were in the ambulance, and that the midwife told her "this was an ambulance, and it did not have drinks".
There was no formal criticism of the local ambulance service but the report highlighted delays and gaps in staffing.
Timeline of events:
- 12.36am - After seeing the midwife, the woman's pain intensified at home and her partner called an ambulance.
- 1am - Ambulance arrives at the family house and got her to the local hospital before 2am. She was asked to rate her pain with a score out of 10 and replied "12".
- 2.27am - The woman's care was escalated. She was told she was being moved to a tertiary hospital in a main centre. An ambulance is called but is prioritised as a patient transport service, a non-urgent transfer.
- 2.46am - Ambulance service contacts hospital to ask how urgent the case is. Records show: "Advise [that] the [patient] can not wait. Need to get there sooner rather than later."
- 2.48am - Ambulance service records show no-one being on roster to make the transfer. Patient is told of a two-hour delay.
- 3.59am - Ambulance arrives at local hospital.
- 4.16am - Ambulance leaves with patient onboard and lights flashing. (Midwife is also onboard).
- 6.07am - Ambulance arrives at tertiary hospital in main centre.
- 6.40am - Baby is delivered and later dies.