A newborn died in a waterbirth and in another case a mother died from blood loss following the delivery of her baby, according to a report out today on things that went seriously wrong in hospitals.

The report by the Health Quality and Safety Commission says there were 454 "serious adverse events" reported by district health boards in the 12 months to the end of June.

This is 4 per cent more than in 2012/13, which commission chairman Professor Alan Merry said this is only a "slight" increase.

Waitemata DHB's cases included:


* A neonatal death associated with a water-birth, in which the use of a water birth was appropriate and no adverse factors were noted in the baby's or mother's wellbeing during labour.

* A woman died after suffering a severe postpartum haemorrhage at home following a birth. There had been limited briefing of maternity unit staff prior to the patient's arrival and the appropriate emergency call pathway was not followed, but this did not contribute to the outcome.

* A newborn inhaled meconium (fetal poo), air in the space around the lung and had a stroke during labour and birth. The DHB says the current guidelines for fetal heart-rate monitoring "did not include duration required of monitoring for reduced fetal movements".

The Auckland DHB reported that a dental patient was taken to the wrong operating room and anaesthetised for hernia surgery. The error was detected in time and the correct - dental - treatment was done.

An Auckland DHB patient died following delays in the diagnosis of meningitis. The case involved an "unusual clinical presentation" and "hand-over issues between emergency department and inpatient team". It was uncertain if earlier antibiotic treatment wold have saved the patient.

Four women at Auckland DHB had foreign bodies left inside them - in three cases a swab - during obstetric or gynaecological treatment.

The commission said that in 73 of the 454 cases, the patient died.

A further 104 serious adverse events were reported by non-DHB services, such as private hospitals, aged care homes, disability services, hospices and the National Screening Unit.


Falls were the most frequent cause of harm reported by DHBs, comprising 55 per cent of all their serious adverse event cases.

Professor Merry said: "Ninety-eight people suffered a broken hip in hospital. This rate of harm is for too high, and equates to almost two patients every week suffering such an injury. This is very disappointing given the considerable effort going into reducing harm from falls, and shows this must continue to be an area of high priority for the commission and the sector."

He said the slight increase in the number of reported serious adverse events is likely to reflect the health sector's increasing commitment to improved reporting of cases.