For five years, Susan Faamoe has kept the ashes of her daughter and grandson in her living room, haunted by unanswered questions. Now, the Coroner has released her findings into the deaths of Emerald Tai and her 3-day-old son Tanatui. Senior journalist Anna Leask reports.
Emerald, 27, and her newborn son died at their West Auckland home in March 2020, hours after leaving Auckland City Hospital against medical advice.
Both had sepsis, and the coroner said it could not be determined whether the baby died solely from infection or also from suffocation while sleeping under his mother.
The case prompted investigations by Health New Zealand (formerly Auckland District Health Board) and the Health and Disability Commission (HDC) into Emerald’s care, including whether sepsis warning signs were missed and discharge protocols followed.
Coroner Erin Woolley also investigated, releasing her findings today.
“After reviewing the HDC’s report and recommendations, I decided to resume the coronial inquiries into Emerald and Tanatui’s deaths to determine their causes,” she said.
“I have also made comments aimed at preventing similar deaths, particularly regarding Tanatui.”
Emerald’s mother Susan Faamoe said it had been agonising waiting five years for answers.
“I want it to all come out,” she said.
“It’s been a long time, it’s been very hard.”
Faamoe still has her daughter and grandson’s ashes, surrounded by photographs, in her living room.
“I’m not ready to put her in the ground yet … and it’s good for her kids to see her and have somewhere to come and say goodbye.
“Her kids can come and see her face - the little ones don’t remember their mother. Some of the kids have lots of questions.”
She has recently set up a new fundraising page to support her grandchildren, so she can contribute to their education and everyday life.
Woolley’s report outlines Emerald’s pregnancy and the birth of Tanatui, her seventh child with partner Tana Samuels.
Other than “excessive bleeding after childbirth”, her pregnancies had no complications. Emerald had limited antenatal care, seemingly by choice.
At 37 weeks on March 5, she attended a midwife clinic and was diagnosed with anaemia.
She was given iron supplements and referred to an obstetrician, who scheduled an iron infusion, but Emerald went into labour before it could happen. She was advised to update her address so midwives could contact her after birth.
Emerald arrived at Auckland City Hospital at 8.30pm on March 13 in late labour.
The labour progressed quickly and Tanatui was born at 9.19pm.
He was healthy but required observation because meconium had been noted in the in-utero fluid.
“Meconium, the baby’s first stool, if present in the womb, can lead to inhalation and serious health issues including infection,” Coroner Woolley said.
Around 6pm the next day, Emerald asked to be discharged to return home with Tanatui.
Hospital staff advised her to remain under observation for at least 24 hours due to high risk of post-partum bleeding and Tanatui’s meconium exposure, but she chose to leave. She signed a “discharge against medical advice” form.
She was advised to monitor Tanatui for signs of increased temperature or breathing difficulties and seek urgent care if needed.
Staff also discussed safe sleeping and provided a pēpi pod.
Emerald returned home to Kelston with her partner and children.
Her hospital records listed a Blockhouse Bay address and her mother’s house in Avondale as contacts.
The community midwife texted to say she would visit but went to the Blockhouse Bay address. Calls and messages went unanswered.
That night, Emerald told her partner she felt hot and in pain before they slept on the lounge couch. The rest of the family slept on mattresses on the floor.
The next morning at 10am, her partner found them cold and unresponsive. Neighbours called emergency services but Emerald and Tanatui could not be resuscitated.
Emerald’s death was caused by puerperal sepsis – a bacterial infection developing within 10 days of childbirth, miscarriage or abortion.
“Puerperal sepsis was once very common, but deaths have declined due to antibiotics and improved maternity care,” Woolley said.
“About 1 to 3% of women having babies are affected.”
Tanatui had sepsis and acute pneumonia in one lung.
He was found sleeping on a couch with his mother in an unsafe prone position, partially underneath her, which could have caused suffocation.
The pathologist could not determine if he died from sepsis alone or combined with asphyxia from unsafe sleep.
Testing showed methamphetamine in Tanatui’s liver but not in Emerald.
“This discrepancy could be explained by environmental exposure, but how infants process methamphetamine is unclear,” Coroner Woolley said.
The pathologist could not conclude methamphetamine’s role in Tanatui’s death.
Faamoe insisted her daughter did not use drugs, saying she only smoked cigarettes.
The HDC investigation focused on whether the Auckland District Health Board provided appropriate care from labour through discharge and postnatal care.
The HDC described the events as tragic and understood the family’s concerns. Some care aspects could have been better, but there was no breach of the Health and Disability Services Consumers’ Rights.
The HDC was mildly critical of the reading or response to subtle abnormalities in Emerald’s vital signs.
Post-partum sepsis can develop rapidly and is difficult to diagnose because signs are subtle.
Emerald had a raised temperature, elevated heart rate, low blood pressure and abdominal pain – symptoms that could indicate infection but also other factors.
The HDC accepted no immediate red flags were raised but said a dedicated maternal sepsis guideline might have prompted more consideration.
Emerald’s case highlighted the complex situations health providers face in caring for pregnant and post-partum women, especially with limited antenatal care and complex social circumstances.
HNZ has since made improvements, updating guidelines, training staff on maternal sepsis, developing patient resources, and improving discharge and midwife handover processes.
The HDC recommended reviewing address confirmation at discharge and reporting on the Maternal Sepsis Screening Tool’s use.
Coroner Woolley made no formal recommendations to prevent similar deaths but urged that safe sleeping advice be widely shared.
Tanatui died in an unsafe environment, co-sleeping with an adult amid loose bedding, increasing the risk of suffocation or smothering.
At discharge, Emerald was given safe sleeping advice: the baby should sleep on its back, in its own bed, and away from smoke.
Records show Emerald knew safe sleep practices, but said she co-slept with all her other babies and was a current smoker.
Staff offered smoking cessation support and provided a pēpi pod – a plastic baby bed allowing close contact without suffocation risk.
The coroner noted that adults and children cannot control their movements during sleep. Therefore, babies should always sleep on their backs in a firm, flat space with no pillow and with their face clear.
Faamoe said she missed her daughter every day.
“I miss her smile. She was always bubbly and happy. She always came over for breakfast … I miss everything,“ she said.
She has set up a Givealittle page to support her growing grandchildren, determined they will not go without as they grow older. All funds will be used for clothes, shoes, uniforms and other essentials.
Auckland Hospital spokesman Carl Eagleton said changes were made following a review into Emerald and Tanatui’s deaths.
He reiterated that Emerald “was advised to remain in hospital” by staff and had been provided with the pepi-pod.
Eagleton said the hospital was “committed to providing safe, high-quality care for the community.
He said the changes made after the review included:
“We extend our heartfelt condolences to this family for their loss, and recognise the deep impact these deaths have had, and will continue to have, on loved ones,” Eagleton said.
Anna Leask is a senior journalist who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for almost 20 years with a particular focus on family and gender-based violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz