A newborn baby suffered brain damage after a paramedic used the wrong method to administer oxygen when she was born in the back of an ambulance.

The Health and Disability Commissioner today released a decision that found St John Ambulance's dispatch policy was also at fault because the paramedic was working alone - meaning he had to pull over to the side of the road in order to help the woman give birth.

The ambulance has since implemented a double-crewing policy and removed all its single-crewed services as of 2021.

This incident happened in 2018 when a woman went into labour close to midnight and took an ambulance to hospital with her sister riding in the back for support.

Halfway to the hospital the sole paramedic, who was driving the ambulance, pulled over and helped deliver the baby and then continued driving to the hospital.

The woman's sister told the Health and Disability Commission that when the girl was born her skin was "grey and purple" and she was very quiet and did not open her eyes.

"She began taking short sucking in type breaths by moving her bottom lip only. There was no sound of her breathing out," she told the Commission.

She also recalls telling the paramedic that she didn't think the baby's breathing was right.

He agreed and administered oxygen to the baby via the "blow-by" method which is where an oxygen tube is held close to the face without the use of the mask. The sister was then instructed to hold the tube near the baby's mouth and to wave it from side to side.

After which she said "she began to slowly gain a little pink colour to her skin. Her breathing continued with little sucks of air inward at the same spaced out rate however … she continued to remain silent and still, with her eyes closed — moving only her bottom lip."

Upon arriving at the hospital a midwife found the baby was floppy, pale and grunting and in overall very poor condition. The baby was then admitted to a neonatal unit before being diagnosed with brain damage from oxygen deprivation.

In its findings the Commission found that the paramedic was cognitively overloaded in having to both drive the ambulance, and treat the patient and her baby at the same time.

It sought expert evidence from Dr Don Banks who said that a bag and mask should have been used to give the baby oxygen instead of the blow-by method.

"It is probable that he failed to recognise or has misinterpreted the seriousness of the baby's presentation."

In their findings the Commission found that the paramedic had breached the Code of Health and Disability Services Consumers' Rights by failing to provide care to the baby of an appropriate manner.

"I acknowledge that Mr B was an experienced paramedic and that this was a complex and rare situation," the Commissioner said.

"He was not well supported by St John in his clinical decisions and actions. As the sole paramedic responsible for two patients, there is little doubt that he had an increased cognitive and practical workload."

The report found that the paramedic did not undertake a full assessment of the baby at birth, specifically her heart rate, respiratory rate, and any other signs of distress she displayed, which led to a failure to recognise the severity of her symptoms.

He should have administered oxygen by manual ventilation or with a bag and continued to do so until arriving at the hospital.

The paramedic involved finished his employment with St John in 2019, and since then has not worked in the health sector in any capacity. He noted that the reasons for this were complex, and the "stress associated with this complaint cause] a significant reduction in his personal health and wellbeing."

The woman and complainant said that following the report she hoped everyone involved would be able to gain closure and not carry a lifelong burden.

"I am happy to see St John's have made some acknowledgement in the way the incident was handled and welcome wholeheartedly the changes they have made."

-By Jeremy Wilkinson
Open Justice multimedia journalist


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