A review ordered by Auckland Hospital after mothers and their babies died has found systemic problems, including staff feeling overworked and unsupported in an environment described as toxic, a Herald investigation can reveal.
Four women died during or soon after giving birth at the country's largest hospital in March and April last year, including during Covid-19 lockdown restrictions. In three of those cases, babies also died.
The Herald revealed the highly unusual cluster of deaths in May last year, and has now obtained the findings of an independent review into the tragedies.
Auckland DHB says the vast majority of recommendations from the review have been or are being implemented.
An expert panel reviewed the DHB's own investigations into the four maternal deaths and concluded 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. They include:
• Staff reported bullying and racism, a disconnect and lack of trust with leadership and described a work environment as toxic and "sink or swim". Some staff lacked cultural competency and "genuine concerns were raised regarding institutional racism". Continuity of care could be better, particularly for Māori and Pacific women.
• Midwife shortages were having a "significant impact on service delivery", a large number of those interviewed said. "Staff are experiencing increasing levels of stress and distress. There is also insufficient time to deliver quality midwifery care (e.g. support for breastfeeding)," the review found. Nurses sent to the maternity ward "feel abandoned, experience a negative attitude towards them and are subsequently reluctant to return".
• A large number of women living outside the DHB boundaries are nonetheless giving birth at the hospital, creating "unsustainable" extra demand, the review warned, and restrictions should be considered. Theatre capacity is inadequate, and "several interviewees noted that this has been on the organisation's risk register for 10 years".
• There are 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".
• Discharge and handover processes were complex, and "women can fall through the gaps".
"While some of these wider system issues may not be direct contributing factors to the seven deaths, the panel cannot discount a potential link," the report concluded.
"[These are] impacting on service delivery, staff morale and wellbeing, and ultimately patient outcomes."
Individual "adverse event" investigations were done by the DHB into the maternal deaths. It refused to release the full investigation reports, citing privacy, but listed 18 associated recommendations, covering issues including staff workloads, and better guidance for identifying sepsis and for treating "unbooked" women who've had little antenatal care.
In March, the Herald revealed the DHB had concluded that "lack of access or co-ordination of care" was a notable finding in three of the cases.
The deaths include Emerald Tai, who died from a post-birth infection with her 3-day-old son Tanatui at their home on March 16 last year.
The husband of another woman who died during lockdown previously told the Herald of not being allowed at the hospital when they lost their baby at 21 weeks' gestation, waiting at home during and after his wife's surgery - and then being called hours later to learn she was close to death in intensive care.
A family spokesperson said the grieving husband was upset to read his late wife's care was deemed only "appropriate". He is considering his response.
Maternal deaths are rare - only one was recorded by Auckland DHB in the previous three years.
The wider review was completed by Margareth Broodkoorn, chief executive of Hokianga Health; Sue Bree, Northland DHB's director of midwifery; and John Tait, chief medical officer at Capital & Coast DHB and chair of the Perinatal and Maternal Mortality Review Committee.
Staff were "extremely dedicated", they said, but the hospital was viewed as a tough place to work. Midwives said their pay wasn't enough to make up for higher costs including parking, housing and transport.
Another problem: disconnect and lack of trust between leadership and staff, who were frustrated that their suggestions to improve things hadn't been acted on. Some staff told the panel they were worried the recommendations made after the individual maternal death investigations wouldn't be properly implemented.
"Most of the staff interviewed had no knowledge of the recommendations (unless directly involved)," the review found. "There is a risk of insufficient staff capacity to implement the recommendations."
Auckland DHB says the vast majority of recommendations from both the individual reports and overarching review have or are being implemented. Changes include more staff and senior positions on wards, a new maternity IT system and efforts to improve culture and support.
The DHB is recruiting for a new director of women's health, after Dr Rob Sherwin left the position in June to return to the UK.
In an interview with the Herald, Auckland DHB director of provider services Dr Mike Shepherd said the public could be reassured that women's health services "deliver excellent patient outcomes". However, "we are also striving to do better", including for staff who "work really hard and do an incredible job".
"When staff morale and wellbeing is not as good as it can be, the international literature shows that is going to have an effect on the quality of care that we deliver. That's the reason for getting on with these recommendations and trying to improve our services."
The review found lockdown hadn't materially affected the care of the women and babies who died, but added to the trauma for some families and staff.
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.
Auckland DHB chair Pat Snedden told the Herald there had probably never been a time "where there is more stress and strain in the place".
"It's very hard to get midwives, because we don't have any chance of getting people into the country, and we are up and down through the Covid process".