An uncle of a young mother who died six hours after giving birth says changes must be made so new midwives are mentored after graduating.

A coronial inquest at Hamilton yesterday heard the last of the evidence into the 2012 deaths of Casey Nathan who died six hours after giving birth and her son Kymani who died two days later.

Whanau members of Ms Nathan could be seen crying in the public gallery as coroner Garry Evans summed up the evidence and noted several factors he would be considering before releasing his findings.

Among these is whether new midwives should undergo a mentoring scheme possibly in a public hospital for 12 months.


Outside the inquest, Ms Nathan's uncle Tem Ormsby was unsure whether the eight-day hearing had provided the answers his whanau wanted but he hoped for change.
He said qualifications for midwives on their own "may not be necessarily satisfactory" and graduates should be further mentored.

"I hope there's change that will take place so that no further members of other families go through this as we have," he said.

Earlier the inquest heard more about Ms Nathan's lead maternity carer's apparent lack of experience.

St John emergency medical technician Roseanne Ford said she had earlier arrived at the birth centre with two neonatal nurses about 12.10pm to take Kymani to hospital.

She described scenes in the delivery room as something she "will never forget".

Ms Nathan was lying on the bed naked from the waist down. She was moaning and thrashing her arms and legs around.

"Her eyes had rolled back into her head. She appeared to me to be in irreversible shock, so she was unconscious."

Ms Ford thought more should have been done for Ms Nathan by the LMC, who has interim name suppression, and other midwives assisting her. She accused them of having a lack of professionalism.


"It appeared to me that they were not doing anything for the patient...they did not ask me to help nor did they say a word."

St John Ambulance officer Wendy Phillips told the inquest she had rushed a dying Ms Nathan to Waikato Hospital.

She was "appalled" when she later overheard a conversation between Ms Nathan's LMC and another midwife that she should put the incident "down to experience".

"The fact that we had rushed a seriously ill person and there didn't seem to be any concern about it, it shocked just put it down to experience, it was just the tone."

St John Ambulance intensive care paramedic Nigel Dawson told the inquest he rushed towards the Huntly Birthcare Centre to meet the ambulance Ms Phillips was driving with a critically ill Ms Nathan inside.

He was confronted by her partner Hayden Tukiri who was being physically aggressive towards himself and his partner while Ms Nathan was "as close to death as possible without being dead".

Ms Nathan's LMC was sitting in the ambulance's dickey seat and had little idea about what was happening and sat and watched.

"I asked her what was going on 'she replied 'I don't really know'."

He asked the LMC if she had considered whether Ms Nathan had suffered a uterine rupture, a pulmonary embolism or a post partum haemorrhage.

"She appeared to be very unsure of herself and what was going on. I don't think she knew how seriously ill the patient was."