Baby Sage Lewis was alive for only one day, 15 hours and 42 minutes.

But it was apparent he was cherished for every second of the brief life he spent with those who loved him, Coroner Ian Telford said in his report into the baby’s death.

“This is a deeply sad case, in which two parents and their family have suffered the devastating loss of their baby boy almost immediately after his birth.”

Sage died from perinatal asphyxia, which happens when a newborn does not get enough oxygen and blood flow before, during, or right after birth.

He died after a rare condition during pregnancy was missed on “successive occasions”.

But his mother, Hannah Nicholson, told NZME that while failures in the duty of care were apparent across multiple providers, the “transparency and acknowledgement of these shortcomings have been significant”.

“Being open about what went wrong has helped drive important systemic changes, which will hopefully prevent other whānau from experiencing such a tragic loss,” Nicholson said.

On the evening of November 14, 2019, at 38 weeks plus one day gestation, Nicholson’s labour was induced at Rotorua Hospital after the spontaneous rupture of membranes the previous day.

Labour progressed normally until a sudden drop in Sage’s heart rate at 7.28pm.

A decision was made for an emergency caesarean section, and Sage was delivered at 8.33pm in poor condition and not breathing.

The senior medical officer noted a clot in the uterus and assessed there had been a placental abruption.

Resuscitation was begun immediately, after which Sage was transferred to the Special Care Baby Unit before being transferred to Waikato Hospital.

He continued to deteriorate, and it was assessed he was unlikely to survive. It was decided to cease active treatment.

His death was recorded at 12.15pm on November 16, 2019.

Post-mortem findings were consistent with significant blood loss, and microscopic examination showed changes consistent with a lack of oxygen to his organs.

The umbilical cord was found to be abnormally attached to the membranes surrounding the placenta, rather than directly to the placenta, a very rare condition known as a velamentous cord insertion.

As a result, the umbilical blood vessels travelled through the membranes without the usual protective tissue surrounding the vessels within the umbilical cord.

In Sage’s case, one of these unprotected blood vessels, the umbilical vein, was torn.

The tear caused significant bleeding, and this was the likely source of severe blood loss that left Sage in such poor condition at birth.

There was no evidence of an underlying weakness in the blood vessel that would have made it prone to tearing.

Health NZ review finds condition missed on ‘successive occasions’

After Sage’s death, Health New Zealand (HNZ) Lakes conducted a learning review to investigate what happened, how it happened and why it happened, including factors relating to clinical care, communication, staffing, working environment and the wider healthcare system that may have contributed to the outcome.

The review noted that, at 20 weeks and two days’ gestation, an ultrasound identified an additional section of placenta, a succenturiate lobe, with blood vessels running close to and overlying the cervix, a condition called vasa praevia.

Vasa praevia is when fetal blood vessels, unsupported by the protective substance of the umbilical cord or placental tissue, lie within or close to the membranes over the internal cervical opening.

In the setting of a succenturiate lobe, such vessels may connect the main placenta with the additional lobe and may therefore pass across or near the cervix.

The significance of this is that, if membrane rupture or labour occurs, these exposed fetal vessels may rupture, potentially resulting in rapid and severe fetal blood loss.

During a review on August 1, 2019, it was planned that if the vasa praevia persisted, an elective caesarean section at 36 weeks would be recommended.

Baby Sage Lewis was born at Rotorua Hospital. Photo / Andrew Warner

Nicholson was then regularly monitored through routine scans, antenatal appointments and visits with her lead maternity carer (LMC).

At 25 weeks, Nicholson was admitted to Rotorua Hospital with a small antepartum haemorrhage.

Scanning reported a succenturiate placenta but no signs of vasa praevia.

The review states this was assessed to still meet some guidelines for diagnosis of the condition, concluding this scan showed evidence of vasa praevia, but it was not recognised.

At 30 weeks, she had scans indicating vasa praevia was still present, but it was not explicitly stated in the radiology report.

A day later, Nicholson’s LMC referred her to hospital with high blood pressure. During that admission, the 30-week scan report was noted.

Nicholson was seen by medical staff on two consecutive days, but no further comment was made about the 30-week scan findings.

Presence of a vasa praevia at 30 weeks did not appear to have been recognised by the medical staff during this admission, and she was discharged.

On October 3, at 32 weeks, Nicholson was admitted to Rotorua Hospital.

At medical review, the doctor recorded, in relation to the 30-week scan, that it “showed succenturiate placenta but no vasa praevia”. She was discharged the next day.

At 33 weeks, an ultrasound scan report stated, “vasa praevia identified at 20 weeks, not present at 25 and 30 weeks”.

The condition was said to have resolved.

There were no scans between 34 and 35 weeks, and Nicholson cancelled a 36-week ultrasound.

She was seen at 37 weeks and then went into labour before she could attend a follow-up scan.

“I consider the review’s central findings to be that vasa praevia was missed on successive occasions and, critically, that at no point were the risks associated with unresolved vasa praevia discussed with Ms Nicholson,” Coroner Telford said.

Health NZ makes changes

Following the review, HNZ Lakes developed and implemented a care pathway for prenatally diagnosed vasa praevia and socialised this with staff. The condition has also been added to the list of conditions now referred to the high-risk clinic.

Other recommendations focused on communication between LMC providers and professional and organisational matters aimed at improving diagnostic and treatment responses.

Since Sage’s death, updated guidelines have been published that provide greater clarity for clinicians working in this field on the diagnostic criteria for vasa praevia.

Telford said he was struck by the “dignified calm in the face of such profound and enduring grief” shown by Nicholson and Sage’s grandmother.

“I was struck by their focus on what could be learned from what had happened to them, and on how those lessons might help to prevent a similar tragedy from occurring in the future. I acknowledge their approach and the considerable strength that it reflects.”

Coroner Telford said he was satisfied that HNZ Lakes had undertaken a comprehensive review and that the recommendations arising from the review were likely to significantly reduce the risk of similar events occurring in the future.

He made no further recommendations, instead encouraging HNZ Lakes to share the learnings from the work with other centres.

Alan Wilson, group director of operations for HNZ Lakes, said in a statement that it accepted the findings and had implemented multiple changes mentioned in the report.

“We acknowledge the profound and enduring impact of Sage’s death on all those who loved him.”

Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.

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