By STACEY BODGER
ROTORUA - The last time Aron and Natalie Van Leeuwen saw their mother, she had just given birth to their baby brother, Matthew, in Rotorua Hospital.
Two days later, Jeanette Van Leeuwen died in the hospital from a severe infection that caused a fever and vomiting, but was not diagnosed by doctors or midwives.
Yesterday, Rotorua coroner David Dowthwaite gave his report on Mrs Van Leeuwen's 1998 death, and expressed concern at the lack of communication between hospital staff and independent midwives about her condition.
Two days before she went into labour, Mrs Van Leeuwen, aged 36, scratched her leg on a picnic table.
She was vomiting and had a fever before she gave birth to Matthew on December 19, 1998.
Rotorua Hospital obstetrician Dr Ramesh Thacker examined Mrs Van Leeuwen and suspected she had either a viral infection or a stomach upset from something she had eaten.
But Rotorua pathologist Dr David Taylor later found that Mrs Van Leeuwen's symptoms were most likely caused by a rare streptococcus A infection, probably from the scratch on her leg.
Mrs Van Leeuwen, described by her family as a positive, bubbly woman, told doctors after the birth that she was feeling better.
But her condition fluctuated and two days later, a senior medical officer called to examine her prescribed antibiotics.
But it was too late, and she died four hours later from severe blood poisoning.
Marcel Van Leeuwen arrived at the hospital on December 21, 1998, to find staff trying to resuscitate his dead wife.
Mr Dowthwaite found that Dr Thacker's incomplete diagnosis had taken on "a life of its own," preventing staff from diagnosing the true infection and prescribing antibiotics.
Mr Dowthwaite said her care had also been affected because she was seen by two Births Are Us midwives, two hospital midwives, a nurse, an obstetrician and a doctor, and no one person was ultimately responsible.
"I believe ultimate decision-making ought to rest with one responsible practitioner throughout," he said.
Yesterday, Marcel Van Leeuwen said the report made no difference to his family's grief.
"Ultimately, no one will be found responsible for Jenny's death - I can't be expected to tell my kids when they grow up that their mummy died because of a lack of communication," he said.
"We still have heaps of unanswered questions that we were hoping the report would resolve."
Lakeland Health services director Johan Morreau said the report was fair and highlighted issues already being addressed by hospital staff.
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