An investigation has found that a slightly premature baby who died while the nurse caring for him died while she was away should have been tested while she was away.

The Health and Disability Commission report said the incident highlighted the challenges of caring for late preterm babies born between 34 and 36 weeks, who often appear healthy but face increased risks.

The baby boy died at Auckland City Hospital in 2020, two days after being born by “semi-emergency” caesarean section at 35 weeks and three days pregnant.

His mother complained to the Commissioner that his care felt rushed, lacked empathy and that staff did not take her concerns seriously enough.

A feeding tube was also inserted without her consent.

After spending 17 hours in the mother-infant combined care area, the baby was moved to the postnatal ward with her mother rather than the neonatal intensive care unit (NICU).

He was having trouble feeding and had a tube passed from his mouth to his stomach. His mother was taking opioids for a pain condition, so he had jaundice and was being monitored for neonatal abstinence syndrome.

He was vomiting, but his mother and medical staff could not agree on how much.

The night the boy died, the nurse taking care of the boy took an hour-long meal break and returned to check on the boy, who was vomiting violently and not breathing.

He could not be revived.

The nurse told the director to ask the midwives in the ward to check on the baby when she left the hospital, but the midwives told her that none of the patients needed anything while she left.

New Zealand Health said it was not normal practice to check the baby every hour in any case, and if very close monitoring was required he would have been admitted to the NICU.

Deputy Commissioner Rose Wall expressed sympathy for the extremely tragic loss of Baby A’s whānau and said serious complaints needed to be considered carefully.

According to the report, the specialist nurse who investigated the case noted that the baby should have been tested at least once during the nurse’s break. “The baby was placed in an incubator under lights, had an oral gastric tube, was premature, was exhibiting signs of opioid withdrawal, and the mother was sound asleep.”

The nurse said there was also a breakdown in communication between staff and the infant’s mother regarding the feeding tube, and that the mother should have been told more about why the feeding tube was needed.

Specialist doctors found that the baby was properly cared for and monitored by medical staff.

The Commissioner agreed, saying the baby’s symptoms had been monitored and appropriately managed.

However, it was found that his patient rights had been breached by the nurse’s failure to check on him during breaks and by a “clear lack of teamwork” between the nurse and midwife on duty.

“This study highlights the unique challenges of managing late preterm infants after birth and the importance of a team approach to care,” Wall’s report said.

Auckland City Hospital currently had a transition unit for late preterm babies and newborns coming from the NICU.

In a statement released today, the hospital apologized to the baby’s family for the failure and the impact it had.

Operations director Mike Sheppard said he accepted the findings and regretted not being able to meet the excellent standards it set out to deliver.

“We acknowledge the tragic loss experienced by Baby A’s parents and so many others in 2020, and recognize that their grief continues,” he said.

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