Grieving father's warning after hospital failure

Rozzana Paitai, who died from a massive stroke three weeks after giving birth to her baby Jonah.

Hospital never spoke to me after my daughter's unexpected death, dad says.

The father of a young Auckland mother who died in hospital two days after complaining of a sore arm says Middlemore staff failed to tell him how serious her condition was.

Rozzana Paitai's father took her to Middlemore Hospital early on October 21, 2011, after she developed a sore right arm.

The 21-year-old mother of two died two days later after suffering a stroke from a blood clot in her brain, a condition associated with pregnancy.

She had given birth to her second son, Jonah, three weeks earlier.

Her father, Tara Paitai, said he decided to speak out about his family's experience after reading in the Herald about how young, vulnerable Pacific and Maori women felt mistreated when giving birth at Middlemore.

"I just didn't want it to happen to anyone else," he said.

"My last words to her were, 'I'll be back later to pick you up', and I told her I loved her and all that stuff," Mr Paitai said.

The Counties Manukau District Health Board, which contacted Mr Paitai after APNZ sought comment on the case, said it was unaware he had felt "unresolved" about her death and offered to meet him to discuss her case.

Mr Paitai, who said he planned to take the DHB up on the offer, described how traumatic the experience had been for his family.

"When I spoke to the doctors, they said, 'Yeah, she'll be all right. Come back in the afternoon and you can take her home'."

Later that day, he returned to find his daughter "had tubes in her".

"The doctors were going, 'Oh yeah, she might not live.' It was quite heartbreaking."

Adding to the family's distress was news that his daughter had been given an extra dose of the blood-thinning medication heparin due to a staff error.

Tara Paitai with Jonah, 2, son of his daughter Rozzana.

While Coroner Katharine Greig found the error, which occurred after a nurse misread Ms Paitai's test results, did not directly caused her death, Mr Paitai said the way staff behaved was unacceptable.

"I told [Rozzana] that they would look after her and we could go home afterwards. If I had more information, I would have just stayed there. [I] wouldn't have cared about work."

The family also felt blindsided by the investigation into the death.

"They came back to say we need to get all the reports because the coroner was taking over the case. We got interviewed by the police, 11 o'clock on that Sunday night," he said.

No one explained why the police and coroner got involved before the interviews, Mr Paitai said.

While a hospital representative had told him staff had asked his ex-wife whether she wanted to talk about their daughter's case, they had never approached him.

"She would have just shut down, so I never knew about it."

Rozzana Paitai.

His daughter's body was also kept from the family for several days for the investigation.

"They took her away that Sunday night. We didn't get her back until Wednesday. I had family fly in and they were asking where she was and I wasn't allowed to say anything."

DHB chief medical officer Dr Gloria Johnson said a substantial review into the medication error had been undertaken, and processes had been implemented "to reduce the potential of this ever happening again".

"At the time, we understood that we had disclosed this error to the family and we are sorry that they did not feel adequately informed or supported by our staff."

Coroner's findings on Rozzana Paitai

• Died after suffering stroke and swelling in brain due to a blood clot
• This uncommon condition is most often associated with pregnancy
• Ms Paitai had given birth to her second child three weeks earlier
• The extra dose of heparin incorrectly administered to her two days before she died did not cause her death
• The drug error, due to a nurse misreading the time of Ms Paitai's blood test results, could have had "potentially fatal consequences"
• Hospital staff response to the error was slow
• Death was not an avoidable one
• Middlemore Hospital has reviewed processes for error recovery which may have resulted in the slow response to the extra heparin dose
• A new blood test result template has been introduced showing the date and time in several places.