Health officials have admitted failing a woman whose baby died after complications in her pregnancy went undiagnosed at a disorganised Waikato clinic.

The Health and Disability Commissioner today released an investigation into care carried out at the Waikato fetal medicine clinic on a 21-year-old mother whose baby died after an emergency Caesarean section in late 2008.

It found the mother had not received blood and urine tests in her final two consultations at the clinic, despite telling a doctor about significant symptoms of dangerous pregnancy complication preeclampsia.

Hours after the last of her five consultations at the clinic, the woman started vomiting and felt pain in her head like it was about to "explode".


She was rushed to hospital, where she was diagnosed with preeclampsia and forced to undergo an urgent Caesarean section.

The baby was transferred to a neonatal intensive care unit and died a few days later.

The report released by the HDC pins much of the blame for the baby's death on systemic failures in the Waikato fetal medicine clinic.

It was plagued by staffing problems and did not clearly define who should be carrying out various tests, the report said.

A midwife who treated the pregnant woman blamed the clinic's layout for contributing to mistakes.

Its lack of an examining room meant patient assessments had to be conducted in a public toilet in the waiting room, the midwife said.

Waikato DHB admitted its systems had failed the woman, known as Ms B.

"Maternal fetal medicine is a branch of women's health which includes high-risk pregnancy where the mother or baby or both has a problem.

"Four years ago we experienced a massive increase in the number of people using the maternity fetal medicine service.

"A lack of robustness in our systems, coupled with that high demand led to our systems letting Ms B down."

It said a review of the clinic systems had been carried out and several changes had been made since the mistakes were uncovered.

"Our systems are better now and more robust."

The HDC also ordered an obstetrician, known as Doctor A, to undergo three months of mentoring for failing to follow up on the absence of blood pressure recordings and urinalysis results before the baby's death.