Midwife Left Room for 25 Minutes During First Feed, Resulting in Baby’s Preventable Death

A tragic incident that occurred in 2015 at a hospital in Palmerston North has come under renewed scrutiny after a coroner's inquest confirmed the death of a newborn was preventable. The baby, who was just 30 hours old, died due to a lack of oxygen during her first breastfeeding session, which was complicated by the absence of the midwife for a prolonged period.

The midwife, Lesa Haynes, was found to have left the room for approximately 25 minutes during the second hour of the baby’s life. During this time, the baby was not monitored, and when she was found unresponsive, emergency resuscitation efforts were initiated. Despite these efforts, the baby suffered irreversible brain damage and was later taken off life support.

The coroner, Bruce Hesketh, concluded that Haynes had not provided an acceptable standard of care and that it was inappropriate for her to leave the room when she did. He emphasized that the baby’s death was preventable and that the midwife had been “rushing” to complete administrative tasks instead of remaining vigilant during the crucial first moments after birth.

According to the inquest, the baby was born at Palmerston North Hospital, and the parents, who were first-time parents, were guided by Haynes on how to breastfeed the baby. However, the mother recalled being unsure about how to ensure the baby was breathing properly and was told that the baby's desire to breathe was greater than her desire to feed. This, combined with the lack of supervision, led to a tragic outcome.

The father described the situation as “relaxed and casual” at the time, as they were following the midwife’s instructions. However, the coroner's findings have raised serious concerns about the protocols in place for postnatal care and the need for continuous monitoring of newborns during the critical first hours of life.

Coroner Hesketh recommended that the Te Whatu Ora review the definition of the “Immediate Postnatal period” in its guidelines, suggesting that this period should not be limited to the first one to two hours after birth. Instead, he emphasized the need for ongoing assessment of mother and baby, ensuring that any deviations from normality are promptly addressed.

Haynes, who has not commented publicly on the findings since the inquest, accepted that she was absent for an extended period and that she had made a mistake in her judgment. She expressed that she still remembers the day clearly and that she had intended to provide proper guidance to the parents.

The inquest, which took nearly eight years to be heard, has sparked a broader conversation about the standards of maternity care in New Zealand and the responsibilities of healthcare professionals during the critical postnatal period. The incident serves as a sobering reminder of the importance of vigilance and attention to detail in the most vulnerable moments of a baby’s life.

As the coroner’s findings are released, the focus now shifts to implementing changes that ensure similar tragedies are avoided in the future. The recommendations from the inquest are expected to influence policy and training for midwives and healthcare providers across the country.