Women with a life-threatening condition weren't treated properly because of a lack of hospital staff, a watchdog has found.
The investigations point to capacity problems extending beyond maternity services at Counties Manukau DHB, where problems like a lack of staff contributed to the recent death or stillbirth of three babies.
The Maternal Morbidity Working Group (MMWG) is notified when a woman is admitted to intensive care or a high dependency unit while pregnant, or within 42 days of the end of the pregnancy.
It recently looked into cases where pregnant or recently pregnant women had severe sepsis, a condition where the body's response to infection injures its own tissues and organs. Sepsis can lead to shock, organ failure and death if not recognised and treated quickly, and is a leading cause of injury and death for pregnant women in New Zealand.
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The group reviewed 32 sepsis cases over 2016 and 2017. In half, severity of illness could have potentially been reduced if symptoms were picked up earlier.
"This occurred across a range of services and specialities. Early warning score systems were often not used, or not responded to. Many reviews noted delays in admission, being seen, diagnosis, treatment (including antibiotics) and follow up," the report stated.
"There were instances of compromised care delivery due to inadequate staffing and inability to respond to acuity. There was also one repeated delay in access to an operating theatre due to acuity."
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The group is run through the Health Quality & Safety Commission, a taxpayer-funded agency that works with clinicians and health organisations to improve care. Its spokeswoman was unable to provide more detail about cases involving inadequate staffing, including where they happened or if more than one DHB was involved.
The commission was working with DHBs to bring in a "maternity early warning system", she said, which would "establish a consistent process and pathways for recognising and responding to a pregnant or recently pregnant woman's deterioration".
"A national rollout of the system in all public hospitals started in March 2019. We expect that during 2020 all public hospitals will have an effective system for recognising and responding to deterioration.
"Counties Manukau Health has established a project team to work on implementing changes to its maternity early warning system."
Documents obtained under the Official Information Act show staff held talks with Counties Manukau DHB leaders after resourcing problems contributed to the deaths or stillbirths babies - one in 2016/17, and two in 2017/18. None of those cases involved sepsis.
An internal review in September 2018 concluded the 73-bed maternity service was operating under an 11-bed shortfall. Counties Manukau DHB has now launched one-year and three-year work programmes. Changes include a new maternity assessment clinic and more midwife, nursing and support staff roles, including senior positions.
Like other DHBs, Counties has little spare money to fix problems. John Ryan, Controller and Auditor-General, last month said the worsening financial position of health boards was concerning: "In just a few years, we have seen one or two DHBs experiencing financial difficulties to almost all of them budgeting for deficits (and many struggling to achieve those budgets)."