Our exclusive story today on babies dying in one of our major hospitals because there weren't enough midwives, doctors, beds and theatre slots should never have been written.
It should never have been published in a newspaper. Or be put online for all the world to see and be appalled. The story should have never been written or published because this should never have happened.
It is now known that maternity care for South Aucklanders fell below safe standards, as thousands of women were sent home too soon after giving birth. The DHB's own reports say substandard care "resulted in" or "led to" the deaths - but a spokeswoman said those were summary descriptions of complex cases with a range of factors.
It's true, women in South Auckland do present some challenges, sometimes greater than other parts of New Zealand. The ratio of Maori and Pacific Island mothers is higher; housing pressures mean many are transient during pregnancy; there are higher rates of obesity and, correspondingly, diabetes and other complications. More than a third of Counties Manukau residents are classified as the country's most socioeconomically deprived. More than 20 per cent of women giving birth in Counties Manukau aren't even registered with a lead maternity carer, such as a midwife.
All that said, the evidence is damning: A lack of oversight for women with complex conditions; too few medical and midwifery staff during busy times; poor triaging; and limited staff and bed space, including to allow extra elective caesarean lists at short notice or urgent inductions.
Staff tried to cope over the past two years by quickly discharging or transferring patients, but services couldn't meet safe standards of care. Babies died when they could have been saved, alive now in their mothers' embrace.
This has occurred over too long a period of time, as Sue Claridge of the Auckland Women's Health Council says, to some of our most vulnerable people. There is no excuse for this nation to not provide any woman with world class maternity care. It is clear the women of Counties Manukau were let down, and so were the staff at the Counties Manukau District Health Board.
Maternity staff asked management for help, but only some budget requests were signed-off. Counties Manukau DHB leaders now say context wasn't given and they didn't understand how bad things were.
However, we now know district board executives met with maternity leaders in July last year. Notes show the meeting was called after "several concerning adverse events where system issues existed, and appeared not to be addressed in a timely way", with workers concerned about "capacity, model of care and staffing". A September 2018 review found the 73-bed maternity service couldn't cope, and urgently needed another 11 beds.
The DHB has now launched both one and three-year work programmes. Changes include a new maternity assessment clinic and more midwife, nursing and support staff roles, including senior positions.
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Some women and babies in the neonatal unit will move in phases to a general ward at Middlemore, freeing up 22 beds on the maternity floor. A new women's health building is about five years away.
These remedies should have been under way years ago. It is now clear staff tried to cope over the past two years by quickly discharging or transferring patients, but services couldn't meet safe standards of care. Babies died when they could have been saved, alive now in their mothers' embrace.
No, this should never have happened, and it should never be allowed to happen again.