A suspended midwife subjected to scrutiny in the case of a woman whose baby died as a result of a ruptured caesarean scar was also the subject of a formal complaint in 2004.
The woman who made that historic complaint was shocked to hear the independent midwife was still practising.
Fiona Clement was a midwife for Tammylee Rapana, whose baby, also named Tammylee, died on March 3 after her mum's scar from two previous caesarean sections ruptured. The Midwifery Council had already suspended Clement three months before that happened and she had no role in the birth.
But Rapana says she wasn't told Clement wasn't able to assist any more and she was left to find alternative care on her own. Clement said she asked "people" to visit Rapana and tell her she'd stopped being her midwife.
Last week, after reading of Rapana's tragedy in the Herald on Sunday, mother-of-five Jasmin Hansen-McKay was shocked to find Clement was still practising.
In 2004, she had complained about Clement to the Health and Disability Commissioner, who found her rights had been breached.
"It's just shocking that she's still out there practising. It's really disturbing," Hansen-McKay, 35, said. It had taken a huge toll to lay a complaint about her treatment during the birth of her fourth child, Ezra, now 8.
"My experience was bad, but it wasn't as bad as it could have been. It wasn't as bad as Tammylee's."
Hansen-McKay had been planning to give birth to Ezra at home, as she had with her two older children. But she had him in an ambulance on the way to Middlemore, after she and her husband, Johnson McKay, couldn't contact Clement by phone or pager.
The nightmare started at 4.10am when her husband called an ambulance. It arrived at 4.22am and Ezra arrived suddenly at 4.37am and struck his head on the stretcher. They got to hospital at 5.02am, and arranged for another midwife to care for her from then on.
In the report, Clement explained her pager had been under her pillow but had fallen on the floor and she had left her cellphone in her handbag in her car.
The commissioner found she failed to perform enough check-ups during pregnancy; provide contact information for a back-up midwife; maintain adequate records; prepare a detailed birth plan; follow up on Hansen-McKay's progress once labour began; ensure she could be contacted during labour; and explain to the McKays why she couldn't be contacted. He recommended the Midwifery Council consider her competence and whether she should have to practise under supervision.
According to the Midwifery Council, Clement qualified as a general and obstetric nurse in 1969, as a midwife in 1977, and as a psychiatric nurse in 1984. Her practising certificate is suspended, and she is required to work under supervision and have a caseload limit of 60.
Clement, who apologised in writing to the McKays, has appealed her suspension, but neither the council nor her lawyer Carla Humphrey would discuss the reasons behind her latest ban.
Meanwhile, Counties Manukau DHB has launched an investigation into baby Tammylee's death and that of another baby, Bella Smith who died in December after her mother Sara's uterus also ruptured.
Rapana said Counties Manukau representatives had told her a review would take months. They had promised to try to locate her baby's placenta which was missing. She gave written permission for the DHB to reveal details.