A raft of changes have been made to maternity care by the Auckland District Health Board after the death of a mother and her baby three days after she gave birth.
An investigation revealed a number of gaps in the system that enabled the new mum to self-discharge with "early indications" of an infection to an address not listed with health-care providers.
Further, details of her case were not passed on to the community midwife so when she could not contact the new mum there was no reason for concern when perhaps there should have been.
The ADHB says it is "deeply sorry" for its handling of the patient and has vowed to do better for all women in future.
Emerald Tai and her 3-day-old son Tanatui died at their home in West Auckland on March 16 last year.
Tai died from sepsis, resulting from an infection she contracted after giving birth.
The baby, named after his father, also had sepsis but "unsafe sleeping" contributed to his death.
It is understood Tai died and may have slumped onto her newborn son - the youngest of the couple's seven kids.
An investigation into Tai's care was undertaken by the Auckland District Health Board and the family provided a copy of the final report to the Herald.
Tai's mother Susan Fa'amoe said the situation was "very difficult".
"It's painful … Tana is finding it hard, he's missing Emerald every day and her kids are suffering too - they always talk about their mum.
"Tana has lost his soulmate and his baby and that broke a piece of him ... I have lost my daughter and my grandson who I never got to meet.
"What has happened is unforgivable."
The family have met briefly with the ADHB and a second meeting will be held after they have had time to "digest" the report.
The report stated that it was still unclear how Tai contracted the infection that led to her sepsis.
It said it was possible she was an asymptomatic carrier of the infection and it took hold when she gave birth - but It was also possible she contracted it from another carrier.
Aside from the actual infection - there were a number of things that could have been done better in Tai's case.
The 15-page report contains 10 recommendations that have either been implemented by the ADHB or will be by June this year.
Much of the report deals with the intimate details of Tai's medical care, but the crucial revelations are:
• Staff suspected an infection and took a swab and later Tai described early symptoms of sepsis but they were not escalated as the condition can be "challenging to recognise" and was "often masked by the normal physiology of pregnancy".
• When Tai left the hospital after less than 24 hours - signing a "discharge at own risk" form - her correct home address was not recorded by staff, nor was a complete handover done to the community midwife.
• As a result the midwife went to an incorrect address given by Tai at an earlier medical appointment - and when she could not reach the new mum by phone she left a "standard" "sorry I missed you form" at the house. As the midwife did not have the information about the vital signs and early discharge she "had no reason for concern" about the "unsuccessful visit".
The major recommendations included establishing a memorandum of understanding between social agencies to support better sharing of information and handover of care co-ordination and developing a "robust and risk-based process" for handovers of clinical responsibility for women discharging straight to their home address after birth.
They said an "ideal handover" between the hospital and community midwife would have included a verbal handover and an opportunity for the midwife to speak with Emerald prior to her discharge from hospital where her correct address could have been confirmed.
The review team also recommended a written resource needed to be compiled for women and families identifying "signs of sepsis after discharge".
While Tai was spoken to about danger signs for her baby's health, sudden infant death and safe sleeping - no mention of sepsis was made.
Additionally, the ADHB has developed a guideline for the care and management of women presenting in labour either unbooked or late in pregnancy having received "minimal or infrequent" antenatal care.
Tai had only seen a community midwife twice before she arrived at hospital to give birth.
Her case was one of four maternity deaths in 2020 that were under investigation.
ADHB director of women's health Dr Rob Sherwin said an overall review into all of the deaths was ongoing.
"We would like to acknowledge Emerald and Tanatui's whānau and the tragic loss of their loved ones," he said.
"We understand this must be a distressing time for them and we offer our heartfelt condolences.
"We are unable to provide more detailed comment at this time as we don't want to pre-empt the findings of the overall review, and as the cases are currently with the Coroner," he explained.
"What we can say is that the individual review into Emerald's care highlighted some areas where our systems were not set up to enable equitable health outcomes for all of our women, and for that we are deeply sorry."
Sherwin vowed to make it "easier for all women" to access antenatal care.
"It's important to us that we continue to learn and make improvements to our services and systems, and have either implemented, or are in the process of implementing, all of the recommendations from the review of Emerald and Tanatui's care to help prevent another family from undergoing a similar experience," he said.
He assured women that they could have "confidence" they and their babies would receive "high-quality care" from the ADHB.
"We are proud of the extraordinary efforts our maternity staff go to in caring for women, babies and their whānau," he told the Herald.
"We provide care that is underpinned by evidence-based best practice and when things do go wrong, we take this extremely seriously.
"We conduct a review to learn from each event and put in place systems to reduce the chances of them happening again."