Last year, four mothers and three of their babies died during or shortly after giving birth at Auckland City Hospital, in a highly unusual cluster of tragedy that sparked multiple investigations. The family of one mother and baby have broken their silence to tell investigations reporter Nicholas Jones why change is urgently needed.
Suliana Pasi was pregnant with her second child when she was struck by intense stomach pain and vomiting.
She was dropping weight and, in October 2019, hospitalised for what was thought to be severe morning sickness. Later in the pregnancy, thrush was suspected, then a urinary tract infection.
Pasi was readmitted to Middlemore Hospital in March last year, but over several weeks doctors couldn't work out what was wrong. The 29-year-old had nose bleeds and vomited blood.
While she was there the country was plunged into the first Covid-19 lockdown and Pasi, who had a cold, was kept in her own room.
She lost so much strength that holding the phone to call family became too much. Her desperate husband was turned away when he tried to visit.
Pasi's lungs were failing. At 30 weeks pregnant she was transferred to specialised intensive care at Auckland City Hospital.
A C-section was planned for the next day, but shortly after midnight Pasi's waters broke. She was told to push, and within half an hour her baby was born lifeless.
A heartbeat flickered after 10 long minutes of resuscitation. The little girl they named Reyana clung to life, but died in her father's arms just after 8am.
Later that day surgeons removed Pasi's kidney after a scan indicated it was badly infected. She never woke from the operation.
"That afternoon her beloved husband and her 18-month-old daughter were waiting for a video call to see her," says her mother, Hala Tausia.
"She never got a chance to say goodbye."
After eight days the family were told it could be time to remove her life support - advice given after biopsy results revealed her illness was caused by gastric cancer that had spread through her body and into the placenta.
When the machines were disconnected Covid restrictions meant only Pasi's husband and mother were allowed to be there.
Other close family - cousins, uncles, aunties - were blocked by hospital security. They gathered on the road and, guided by Tausia on the phone, looked to the third floor and found the room to focus their prayers on.
"They stood by the fence and just cried from there," Tausia says.
Pasi was one of four women treated at Auckland Hospital who died during or soon after giving birth in March and April last year. In three of those cases, babies also died.
Such maternal deaths are extremely rare; only one was recorded by Auckland DHB in the previous three years.
The Weekend Herald revealed the cluster of deaths in May last year, and as part of an ongoing investigation in September obtained the findings of an independent review into the tragedies.
That was done by an expert panel, who reviewed the DHB's own investigations into the deaths and concluded that in all cases "the quality of care provided by ADHB was of an appropriate standard".
However, in speaking to staff, patients and reviewing internal documents, the investigation uncovered wider problems, including staff feeling overworked and unsupported in an environment described as toxic.
While the overarching review was released after an Official Information Act request by the Weekend Herald, Auckland DHB wouldn't provide the findings from individual investigations done into each maternal death, citing privacy.
Pasi's family have now shared the documents related to her care. They reveal serious problems, which a leading health advocate says are deeply troubling and should have been fixed years ago.
Her family are speaking out in the hope doing so will drive changes to protect other women and babies. Their grief is raw.
"I really miss her," Tausia says. "I love her. It's like part of your heart is cut off. How can you survive? How can you live?"
A life ahead of her
Suliana Pasi was the eldest of two daughters born to her Tongan mother and her Rotuman Fijian father, Montu Tausia.
She grew up in Apia, Samoa, and after school won a scholarship to study medicine and surgery in Beijing.
"She was good at accounting and other subjects, but she said, 'Mum, I want to help people,'" Tausia says.
Swapping a country of fewer than 200,000 people for Beijing's almost 22 million was daunting, but Pasi took it in her stride. Within a year she could speak Chinese (her fourth language), and worked at a local hospital after graduating.
After six years in Beijing she settled in New Zealand to be close to family. It was here she met her husband, Chetan Sharma, another recent migrant, from Punjab in northern India.
Marriage and their first child, Hadassah, followed.
Pasi was waiting on residency, and planned to study a one-year masters before working as a doctor. The young family didn't have much, but she still put others first, Sharma says. For example, giving money to a church friend who couldn't pay their rent.
"I'd try to tell her she was needy, too … she focused on things that actually matter, instead of being materialistic. Spending time with our daughter, having a meal together - those were the times that were most important to her."
Pasi's Facebook page is full of photos and videos of her daughter: in pig-tails and dancing; on the kids' train at Ambury Park; making "calls" to her dad using a shoe as a receiver; being doted on by her grandfather.
"Spending time with her and watching her grow brings a certain closeness and appreciation for the beauty In God's enduring love, grace and mercy," Pasi wrote in June 2019.
That joy was set to double, but it was during Pasi's second pregnancy that she felt the effects of her hidden cancer.
In October 2019 she went to Middlemore's emergency department at eight weeks pregnant and with vomiting, stomach pain and weight loss. Doctors diagnosed hyperemesis (severe morning sickness), and she later spent several nights in hospital.
In February last year she was back in ED with stomach pain. Doctors suspected thrush. After another antenatal clinic, she went back to the emergency department on February 29. A possible urinary tract infection (UTI) was suspected and she was given antibiotics.
On March 6 she spent a night in hospital after a week of intermittent pain. After being checked at the birthing and assessment unit she was discharged home and told to return if she had contractions, UTI symptoms or if Panadol and heat packs didn't help her pain.
Three days later she was readmitted. Middlemore felt jittery; New Zealand's first handful of Covid-19 cases were emerging. International news showed harrowing footage of state-of-the-art hospitals in Italy being overwhelmed.
Pasi didn't have Covid but it felt like people kept their distance. Meals were often hurriedly left out of reach, she told her family. Some medication was given late.
For three weeks she stayed in the room, scared, nauseous and in pain. Her oxygen levels dropped on March 17 and never properly recovered. The last visit her family were able to make was just before New Zealand went into level 4 lockdown from March 26.
Pasi couldn't sleep, eat or drink easily because of the pain, and had little energy to get off her bed to shower or go to the toilet.
She sent a photo to her mother, who was shocked: blood covered Pasi's nose and a tissue scrunched inside her oxygen mask. She looked extremely sick.
"Mum, no midwife visited me today. They must have panicked with the Covid outbreak. No food has been provided and my room is horrible. I don't have energy for anything," one of her handful of text messages read.
Soon even this sporadic contact stopped. Her family couldn't visit. Nobody updated them on her condition, they say, and when they repeatedly phoned the hospital they were told she was "fine". Her hospital-appointed midwife wasn't returning calls or emails, the family says.
During her hospital stay the cancer wasn't detected and Pasi was instead diagnosed with a kidney infection from a UTI, kidney disease caused by a skin or throat infection, and a blockage in a lung artery. Antenatal steroids were given to mature her baby's lungs in case of premature birth.
On April 1 her lack of oxygen became critical and she was moved to Middlemore's ICU. A scan showed very high blood pressure in her lungs. A few hours later Pasi was put in an ambulance and transferred to Auckland Hospital's Cardiothoracic and Vascular Intensive Care Unit, where she was stabilised.
After Reyana died the next morning, her body was taken to her mother for a first hold.
"She cried. She felt the pain," Sharma remembers. "I thought that was probably the worst moment I'd face. But it turned out to be much worse than that."
A nurse helped him wash Reyana and put her in fresh clothes and a Moses basket. He stayed with her a long time, but eventually left to see Hadassah, and to try to arrange a burial in the middle of lockdown.
That afternoon when specialists explained why they wanted to remove Pasi's kidney, the risks of doing so weren't properly explained, Tausia claims.
"My daughter asked, 'How soon?' They said, 'Now.' She said, 'There's no way for me to have a rest?' Because her husband wasn't there. They said, 'The sooner the better.' They said they wanted to take her straight away. That was their decision."
(The DHB says an intensivist recalls explaining that having a general anaesthetic would be very dangerous, but they were worried about leaving the kidney as it would continue to make Pasi unwell. It is "very saddened" to hear the family felt the risks weren't adequately explained.)
Tausia walked alongside as Pasi's bed was wheeled to a stop before the theatre doors.
"I can't forget it. She turned and said, 'Mum, don't go anywhere. Just wait there for me.'
"That's the last time she was awake."
The lockdown limited numbers at Pasi's burial. Two months later the family farewelled her maternal grandmother, who never recovered from a stroke on the day Pasi - her first grandchild - was sent to Auckland Hospital.
What went wrong
Both Counties Manukau and Auckland DHBs did separate "adverse event" investigations into the death of Pasi and her baby. They found a range of issues, particularly in the handover between Middlemore and Auckland Hospital teams.
"Some key obstetric information was not readily available", the Auckland DHB review noted, including plots of fetal growth, the fact that Pasi's first child had been born prematurely and rapidly, and that on March 26 Middlemore doctors had considered a possible early delivery, before the clear deterioration in Pasi's health and after concerns over the baby's heart rate, which later normalised.
The last ultrasound Pasi had was 15 days before she was sent to Auckland Hospital.
"There was no documented handover information from Counties Manukau DHB on fetal wellbeing and no concerns were conveyed regarding the immediate safety of the fetus, nor information regarding the risk of preterm labour," the review stated.
"As there were thought to be no particular obstetric concerns, a midwife was not allocated to the patient and apart from a CTG [cardiotocography] at 9pm, there was no fetal monitoring planned overnight.
"An ultrasound was not considered at this stage as there was no concern for the fetus. It is likely that a fetal heartbeat was present at this stage because resuscitation of the baby at birth did result in return of circulation for a period of time."
The teams involved in Pasi's care at Auckland Hospital "worked exceptionally well together", the review found. However, the transfer information from Middlemore "was focused on the critically ill mother with little focus on the wellbeing of the fetus".
The impact of this, the review concluded, was that no midwife was assigned to monitor Pasi, and her preterm labour with Reyana in the breech position wasn't detected until in the advanced stages, with no fetal monitoring during the birth.
"It is not possible to know whether an emergency caesarean section for fetal reasons would have changed the eventual outcome for the baby."
In a meeting with hospital representatives after her death, Pasi's family were told the 9pm cardiotocography might not have picked up Reyana's heart rate. Her lack of oxygen was probably caused by her mother having the same problem, and the placenta not working well because of the cancer.
The Auckland DHB review recommended standard operating procedures be developed to ensure comprehensive information when a patient comes into the obstetric service, and that they get a timely assessment by an interdisciplinary team.
Counties Manukau DHB's own investigation found eight issues, including that her symptoms of weight loss, nausea and vomiting were attributed to pregnancy, that different explanations for her worsening health weren't investigated, and "the evolving complexity and deterioration of her condition was not fully recognised".
At the time, there was no obstetric physician to help oversee complex medical conditions in pregnant women, Counties' review found, and unfamiliarity with maternity electronic records by some doctors "may have resulted in an incomplete assessment of Pasi's overall presentation".
"Pasi's admission occurred throughout level 4 Covid-19 lockdown with very restricted visiting. There is no evidence of formal communication with her family or consideration of a psychological assessment during her admission."
Jenn Hooper, the founder of Action to Improve Maternity (AIM), a charity that has helped hundreds of families affected by poor maternity care, told the Weekend Herald it was "infuriating" to know vital information wasn't handed over between the hospitals, given a nationally standardised maternity clinical information system was promised in response to her petition in 2009.
Hooper believes the lack of action has contributed to deaths and babies being disabled because of avoidable birth injuries.
"It went nowhere. And here we are in 2021 with the same issues, and the same promises ... what does it take? Why can't all DHBs be able to access the same information? People move. And people have to be transferred. It's ludicrous."
The Ministry of Health says that by July 2023 a new system will be available nationwide, allowing specific clinical information to be shared across community and hospital systems, no matter what local database is used.
On past efforts to link up maternity information, it says "BadgerNet" software has been available since 2015 (and upgraded since then), which enables real-time recording and sharing of information. Four of 20 DHBs use the system, including Counties Manukau, and another seven plan to do so soon, including Auckland.
Bullying, racism, and high workloads
Tausia tries to forget what happened, but the pain flooded back when in September she read the Herald's story on the maternal death review.
That independent investigation found that hospital staff were extremely dedicated, but were experiencing "increasing levels of stress and distress", including because of high workloads and a disconnect and lack of trust with management.
Midwife shortages were having a "significant impact on service delivery", a large number of those interviewed said. Nurses sent to the maternity ward to help "feel abandoned, experience a negative attitude towards them and are subsequently reluctant to return", the review found.
Bullying and racism was reported by staff, some of whom described their work environment as toxic and "sink or swim".
Some health professionals lacked cultural competency, the reviewers stated, and "genuine concerns were raised regarding institutional racism" (a term that means the procedures, practices or attitudes of particular organisations result in some groups being advantaged).
Continuity of care could be better, particularly for Pacific and Māori women. The report noted concerns about a "two-tier system" enabling women who can afford a private obstetrician to get more timely treatment, including when being induced. This "appears to inadvertently disadvantage non-Pākehā women".
Another problem identified was that discharge and handover processes were complex with "too many risks".
"Out-of-hours transfer of care arrangements mean women can fall through the gaps and be inadequately followed up," the review warned. "There are multiple patient information systems within and across the Auckland region DHBs, which means there is a risk of important information being missed and fragmentation of care."
(Pasi arrived at Auckland Hospital about 4.30pm, by which time the maternal fetal medicine team, who didn't know she had arrived, were off-duty. Maternity clinical notes and observations on Middlemore's electronic system couldn't be accessed by Auckland DHB staff.)
The review concluded that "while some of these wider system issues may not be direct contributing factors to the seven deaths, the panel cannot discount a potential link ...[these are] impacting on service delivery, staff morale and wellbeing, and ultimately patient outcomes."
Auckland DHB says the vast majority of recommendations from the reviews have or are being implemented. Changes include more staff and senior positions on wards, the new maternity IT system and workshops to improve culture and support.
None of the four women who died were Pākehā, and Auckland DHB has included the findings from their deaths into a wider overhaul of women's health services to try to eliminate inequities. That work had started before the cluster of maternal deaths, and is still ongoing, with no final recommendations made.
"At some point, some people are getting a different deal to others. So we need to find out what it is that's contributing to that," Deborah Pittam, Auckland DHB's director of midwifery, told the Weekend Herald in March, of the motivation for that reform.
Pressure on services and midwifery shortages aren't limited to Auckland DHB. Associate Minister of Health Ayesha Verrall recently acknowledged acute issues in the sector and has funded "safety officers" to every DHB.
The maternal deaths review found a large number of women living outside Auckland DHB's boundaries are nonetheless giving birth at the hospital, creating "unsustainable" extra demand, and recommended restrictions be considered.
Auckland DHB has begun talks with Counties Manukau and Waitematā DHBs about this, but they are "similarly constrained", says Dr Mike Shepherd, ADHB's director of provider services.
"There's not a whole bunch of spare capacity in the system."
Shepherd says his heart goes out to Pasi's family, but he can't comment on details of the care because of ethical and privacy reasons.
He noted the various reviews had found the care at Auckland DHB was of an appropriate standard, and he acknowledged the DHB's staff "who are dedicated to doing their absolute best for all our patients and whānau".
Counties declined to answer questions about Pasi's care.
'She remembers her mum'
Last Sunday Pasi would have celebrated her 31st birthday. Her family visited her at Manukau Memorial Gardens, where she lies within 100m from Reyana.
Much more should have been done, they say, particularly in the weeks when Pasi was in agony and alone in Middlemore. Tausia worries her treatment shows that the inequities, institutional racism and cultural competency problems flagged by the Auckland DHB maternal deaths review also apply to Middlemore.
Hadassah is now 3, and has spent half her life without her mum; an absence felt keenly, including when other kids run into their mothers' arms after daycare.
"I try to fit in with that position so she doesn't feel left behind," says Tausia, who has given up work to help look after Hadassah, who she calls by her middle name, Sinia.
"But she still remembers her mum. We have put her photo on the wall, and she lies down and looks at it, and keeps very quiet.
"She must be wondering where her mummy has gone."
Sharma sees his wife's intelligence in his daughter. She learns something once and doesn't forget it, he says. Sometimes she corrects his English. A favourite game is to use a toy doctor's kit to take his temperature and administer medicine.
"[My wife] would have loved watching her growing up.
"At any important time in her life - when she'll go to school, at her graduation - she will miss her mother, and I'm going to miss her too, not having her stand next to me.
"It's an endless pain. Whenever we need her most, there's going to be a gap."