Coroner finds rare umbilical condition was missed before newborn's death

A coroner has found that Sage William Mana Lewis died from perinatal asphyxia after a rare umbilical cord condition was missed on successive occasions. The newborn lived for one day, 15 hours and 42 minutes, after being born at Rotorua Hospital on 14 November 2019.

The baby suffered from velamentous cord insertion, a condition occurring in approximately 1% of placentas where the umbilical cord attaches to the membranes rather than the placenta. This left umbilical blood vessels exposed without protective Wharton's jelly, making them vulnerable to tearing. In Sage's case, the umbilical vein tore, causing significant blood loss.

A 20-week ultrasound identified vasa praevia, where blood vessels run close to the cervix. Although a plan was made for a potential caesarean section at 36 weeks, the condition was missed during scans at 25 and 30 weeks, and during a hospital admission. The coroner noted that the risks of the unresolved condition were never discussed with the mother, Hannah Nicholson.

Following a review by Health New Zealand Lakes, the condition has been added to the High-Risk Clinic referral list. Coroner Ian Telford described the case as "deeply sad" and noted the family's focus on ensuring lessons were learned to prevent future tragedies.

Where reports differ

• One report notes the mother's labour was induced, while another states it was progressing normally before a sudden drop in heart rate.

Compiled from reports by Waikato Times, Stuff, RNZ, NZ Herald and 1News.