Two investigations are underway after a deadly complication which left a woman in excruciating pain for four days wasn't picked up.
Nicole Kildare, 42, gave birth by caesarean to her son Nikau in Tauranga Hospital on December 22.
She started getting pain in her abdomen the following day and her stomach got bigger over the next four days.
Kildare's medical notes, which she shared with the Herald, show a registrar queried on December 23 if she had Ogilvie syndrome.
Other registrars also saw Kildare and noted she needed intervention.
But while staff kept giving pain relief, no treatment was carried out to relieve the pressure.
"My stomach was massive," Kildare said.
"It looked like I had twins on board. If I was a cow surely they would have put a needle in to get the gas out?"
On Christmas Day, Kildare's pain got worse and her skin turned grey - a symptom of blood poisoning.
On Boxing Day, obstetric consultant Dr Aparna Basu - a doctor she hadn't yet seen - checked on her and ordered an X-ray.
It confirmed her bowel had burst, faeces had spilled into her body, and further tests confirmed she had blood poisoning.
Kildare had developed Ogilvie syndrome - a rare and potentially fatal condition where the bowel expands like a balloon.
If the gas is not let out, the bowel can burst, drastically increasing the risk of death.
She was rushed to surgery where the pressure was released, her abdomen cleaned out and her ruptured bowel fixed.
"If I had been left a few more hours, I would have been dead," Kildare.
Through her whole ordeal, Kildare was unable to feed her newborn son. Husband Jeff, frantic with worry, was left caring for the baby and their two-year-old daughter.
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Kildare is slowly recovering but needs another operation, and says she may need up to two years off work.
She's upset Nikau has missed out on bonding time as she can't lift or breastfeed him. She says she has also been diagnosed with post-traumatic stress disorder, and she and Jeff still have nightmares.
The couple complained to the Bay of Plenty District Health Board about the time it took to diagnose her and about poor communication and overhearing midwives making rude and dismissive comments about her.
"Why [did] they just kept leaving me with a conservative treatment that left me gradually getting worse and worse to the point where I exploded on the inside?"
"We do not want this to happen to another woman child and her family ever again."
The Bay of Plenty DHB apologised in writing in March, admitting a "failure to recognise Nicole's deterioration in a timely way, and to review and escalate the clinical situation to the on-call consultant".
It also admitted staff had been "unprofessional" talking to the family.
The hospital's patient quality and safety manager Debbie Brown told the Herald that the case was under review by the DHB and the Health and Disability Commission.
"We acknowledge Miss Fensom had a particularly traumatic experience when she had her baby," she said, referring to Kildare by her maiden name.
"It is very unfortunate for any new mother to have this type of experience at a time which should be one of excitement and joy.
"We have met with Miss Fensom and her family, and apologised for their experience."
Brown said the DHB was working with Kildare and her family and commission to establish and understand the course of events.
"We are committed to implementing any recommendations which come out of the review. We take all complaints and concerns very seriously, and where we have opportunities to improve and lessons to learn, we always act on these to ensure improved care in the future."