A pregnant 21-year-old was rushed back to hospital hours after seeing her doctor - and lost her baby. She had been sent home without routine checks, including taking her blood pressure.
Yesterday, the Health and Disability Commissioner ruled that the doctor and hospital had failed her.
The Waikato District Health Board says the case, from three years ago, highlights how the hospital failed to cope with the growing number of women needing specialist care.
It says it has improved its systems and there have since been no baby deaths at the specialist unit - the fetal medicine service - which handles high-risk pregnancies for much of the North Island.
But overall, the health board is dealing with more complications because more older women and women with health conditions are getting pregnant.
Health and Disability Commissioner Anthony Hill yesterday released his report into the 21-year-old, referred to only as Ms B.
She became pregnant, for the first time, in 2008 but an early scan showed the fetus was slow to develop.
She was referred to the specialist clinic at Waikato Hospital after her baby was diagnosed as having symmetrical intrauterine growth restriction, a condition caused most commonly by maternal hypertension or a chromosomal abnormality similar to Down Syndrome.
In five visits to the clinic, Ms B was told the chances for her baby were poor.
But on her fourth and fifth visits, the report says, routine checks were not done.
On the fourth visit, her blood pressure and weight were not recorded, and on the fifth, she did not see the midwife, who was to check her blood pressure and urine.
Soon after leaving the clinic, Ms B began vomiting and developed a severe headache.
An ambulance took her back to the hospital and the next day, an emergency caesarean section delivered her baby more than two months prematurely.
The infant died within days.
Ms B's family and her doctor, Dr A, disagree on whether the clinic was notified that Ms B had been having headaches and tingling in her hands and feet - symptoms which would have made the blood pressure checks urgent - when she made her last two visits.
But the commissioner ruled that Ms B's patient rights had been breached.
"I find that Dr A failed to adequately assess Ms B's well-being and follow up the absence of blood pressure recordings and urinalysis at the fourth and fifth appointments, and these were serious omissions," Mr Hill said.
"Waikato DHB failed to provide services of an appropriate standard and failed to provide services in a manner that minimised potential harm to Ms B."
Mr Hill said the clinic's staff had been under pressure because of tightly scheduled appointments.
Dr A told the review that Ms B's missed readings were a direct result of system failures and practical difficulties.
Waikato and Thames hospitals group manager Mark Spittal said yesterday that the clinic's systems had been improved.
"We've learned from these events, and the commissioner's recommendations have been implemented or are in the process of being implemented."
The DHB's associate midwifery manager, Pip Wright, said the number of patients being referred to the clinic had risen four years ago because of medical advances.
"We got a lot more women who had potential abnormalities picked up," she said.
"It was a bit unforeseen, in hindsight. Maybe it should have been looked at that it was going to happen and we should have been proactive rather than reactive."
A Health Quality and Safety Commission report last month on avoidable hospital incidents in the past financial year noted one baby death in the Waikato DHB area, when a midwife failed to monitor a pregnant woman.