The NMBA, AHPRA and their 'Standards'

For those who follow us, you may have seen the news coverage last week revisiting the tragic death of Hugo McGregor at Mackay Base Hospital. Hugo died following 34 separate failures in care.

You can watch the story here: Facebook

In response to this, and in close consultation with Hugo’s parents, Jenna and Andre, we developed Hugo’s 7 Rights of Safe Induction of Labour. This initiative led to the release of Australia’s first consumer-friendly guide to understanding the CTG trace—a vital tool for monitoring a baby’s wellbeing during labour.

Hugo's CTG trace can be found on our website here:

Informed Induction | MaternityConsumerNW

We know that CTG traces can appear overwhelming at first glance, but simply asking the provider key questions can help birthing women and their support people understand what’s happening in real time. We’ve also created a documentation form so that any clinical interpretation of the CTG trace—and the informed consent given—can be properly recorded.

But the heart of why these resources exist comes down to something much deeper: systemic failure by AHPRA and the medical boards that oversee health practitioners.

As long-time advocates, we’ve submitted countless complaints to AHPRA. We are well-versed in the disappointing reality: they often take no action, give vague responses, or fail to address key issues.

In fact, we have good reason to believe they don’t even read the complaints we send them, at least not properly.

What’s more alarming is AHPRA’s/ the boards increasing tendency to excuse even egregious negligence—cases that result in death, near death, or permanent maiming of women and babies—even when these failures are clearly documented in the medical records.

This has left us with no choice but to shift more and more of our energy into building tools for consumers—so that women can secure proper informed consent, recognize unsafe practices, and protect their rights as patients.

This is because when AHPRA and the medical boards do respond, they often claim that "standards of care were met"—even when its blatantly obvious it hasn’t.

Let’s be clear: the “standard” they’re upholding is not safe. It is not lawful. It is not evidence-based. It’s nonsense they pull out of thin air. 

Hugo’s case is a big example...

 According to the Nursing and Midwifery Board, it is acceptable practice for a midwife to miss six hours of compromised fetal heart rate on a CTG trace—and augment a labour with a severely compromised baby and miss hyperstimulation of the uterus for an hour too.

This was in addition to failing to perform the required clinical checks under RANZCOG guidelines, including appropriate palpation of the uterus during labour.

Sadly, this is just one of many similar cases we receive. And it’s important that consumers understand this: while the legal obligation to provide safe and informed care falls entirely on the provider, no one is holding them to account.

No one is enforcing these standards.

And it is killing people—mostly women and children.

Anyway the parents of Hugo have given us permission to share the midwifery assessment of the CTG cand the care they had based on it straight from their medical  notes, (we did formlalise into a proper complaint) (please note this does not cover the additional 34 failures of care they experienced).

So you all have an idea what the Nursing and Midwifery Board thinks is woman centred, safe, standard midwifery care for yourselves:

cx stands for contractions. RM for registered midwife:

JENNA McGREGOR Case Notations

Background:

35yo NZ, G2P0, Low risk pregnancy. Adequate

antenatal care via MPG Proserpine hospital.

Timeline of Events:

10/03/23 1830 G40+5, SROM, pink – phone call to BS

11/03/23 0330 presented to BS for abx, cx 3-4:10, early labour

Transferred to Mackay due to Proserpine service issues (no anaesthetist available for an epidural, but then epidural given until noon at Mackay).

Jenna arrived at Mckay labour ward at 0620 in labour.  Ve confirmed at 7cm and baby position direct OP.

She went into the shower then the FHR was listened to with a Doppler for a few minutes and baby’s hear rate was 160-180bpm.  It was repeated after 5 minutes and was noted to still be at 160bpm so a Ctg was applied. (Not passed on to the family).

Note states that care was then handed over to the morning staff and the ctg was normal.

The ctg print out confirms this, however there is a missing chunk of the trace between 0730am until 0953am.

0910 RM – assessed labour, noted FHR 150bpm, cx 4-10, 75s, baby DOP

Jenna in the bath. Cx 4:10, strong (from clinical notes)

0931 Jenna requests epidural again that she had asked for at 6 am.

0953-1017 CTG commenced. baseline FHR150bpm, key normal features

present but also decelerations with loss of contact (LOC)

1001 RM documents Doppler reading 155bpm, VE stopped not tolerated.

1017-1041 CTG continues. Deceleration ++ and with some contractions.

CTG does not trace cx very well, but RM notes 4:10, strong.

 Fetal

monitoring annotations by RM (1001-1058) comments picking up MHR

and position changes but trace identifies FHR and loss of contact for

MHR. No record of informing Jenna regarding concerning trace

Features.

1041-1105 CTG continues. At 1045 & 1048, prolonged deceleration and

bradycardia. Not noted. No request obstetric review.

1105-1129 CTG is ceased for epidural insertion at 1112. Reassuring features

prior to cessation.

1129-1153 no recording due to epidural insertion.

1153-1217 epidural infusion commenced. CTG recommenced. Between

1200-1206, episode of rising baseline to 160bpm+, then drops to

140bpm, with reduced variability. No concerns noted by RM.

1217-1241 signs of reduced variability, baseline dropped to 135-140bpm.

Documented at 1228 as normal.

1241-1305 baseline dropped to 130-135bpm, all other key features were

Present.

1305-1329 episodes of reduced variability but with key normal features

present. RM note at 1330 normal ctg.

1329-1353 baseline 130bpm, reduced variability but with key normal feature

present. RM note at 1355 cx 3-4:10, strong.

1353-1417 reduced variability. No other key reassuring features are present.

RM note breakthrough pain and contractions reducing. Noted for

syntocinon infusion once pain controlled. No documented informed

Consent.

1417-1441 baseline 135-140bpm, reassuring features present. RM note at

1423 state epidural pump settings incorrect, and correction made. 

1441-1505 baseline 135-140bpm, key reassuring features present. RM

retrospective notes state syntocinon commenced at 1502.-Following after a 2 minute long cx (hypertonus) on CTG. Documented as a normal 60 second long contraction.

 Cx on trace

1:10

1505-1529 acceleration/rising baseline up to 180bpm, then drops to 135-

140bpm, episodes of reduced variability, but a reassuring feature

present. Cx appears to be increasing 2:10. No notes by RM.

1529-1553 reduced variability, with rising baseline. Possible shallow

deceleration with cx at 1542 and 1545. Cx 2-3:10. 1547 increased

syntocinon. RM note cx 1:10, 60s. (different to CTG).

1553-16:00 cx appear to be increasing. Position change noted by RM.

Bradycardia at 1602 (between this time syntocinon increased without obstetric review)

.(The CTG printout at the time of the synto

increase showed contractions occurring every three minutes, lasting longer than 2

minutes (hypertonus), which would not typically justify an increase in synto

without a thorough obstetric consultation.)

1858 Retrospective notes by RM. Bradycardia after 1600, syntocinon ceased.

Code called. Frank flesh blood noted on VE. 1608 IM terbutaline, OBS

in room, 16:11- for theatre. FHR noted at 60bpm.

Argument between anesthetist and RM regarding spinal or GA, until OBs

ordered GA. No FHR at 1620. Baby delivered flatlined and unresponsive at 1632. 

Baby Hugo was resuscitated but died 5 days later as he was completely brain damaged. 

Anyway ....the uh ‘standards of care’ from the Nursing and Midwifery Board via AHPRA.