A cluster of baby deaths and stillbirths at one of New Zealand's biggest maternity services has been linked to a lack of staff, beds and treatment delays. Nicholas Jones investigates what went wrong.
Babies died partly because there weren't enough midwives, doctors, beds and theatre slots at one of the country's major hospitals.
Middlemore Hospital struggled to cope with big increases in the number of pregnancies needing more care and monitoring, and services buckled.
Problems like a lack of staff and beds contributed to the recent death or stillbirth of three babies. Other patients were seriously harmed.
A Weekend Herald investigation has found maternity care for South Aucklanders fell below safe standards, as thousands of women were sent home too soon after giving birth.
Experts advocating for patients and hospital workers have reacted with dismay. One has warned of "clear potential for disaster".
After babies died, maternity leaders applied for help. More staff were hired, but fewer than what was asked for. Counties Manukau DHB executives now say they didn't understand how bad things had become.
Changes have been made or are underway, after a damning internal review found an 11-bed shortfall, and linked a lack of resources to a death in 2016/17, and another two in 2017/18.
• A newborn died after a delayed diagnosis of pneumonia. Monitoring equipment wasn't easily locatable, and there were major communication and documentation problems as staff struggled with double the number of induction of labours than normal.
Special investigation: Why Kiwi babies are dying of a medieval disease
Diabetes amputation horror: 'I was clawing at the walls'
• A baby was stillborn after a breakdown in the coordination of a woman's care, limited caesarean surgical slots and no allocation to a senior doctor.
• Health risk factors for baby and mother weren't properly picked up as a lack of doctors and midwives struggled with high workload. The child was stillborn.
DHB reports say substandard care "resulted in" or "led to" deaths, but a spokeswoman said those were summary descriptions of complex cases with a range of factors. Further details weren't released for privacy reasons, including more information about patients' health conditions.
Other incidents include a new mother falling and snapping her shinbone after being discharged from hospital in February last year, six hours after giving birth and still numb from an epidural. A nurse insisted the 27-year-old move to a birthing unit because all postnatal beds were full.
A few months later, a woman whose unborn baby had stopped moving much wasn't checked soon enough because of factors including a lack of staff and beds. The DHB refused to confirm whether the baby survived, citing privacy concerns.
Health board executives sat down with maternity staff 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". Workers were concerned about "capacity, model of care and staffing".
A September 2018 review, released with other documents under the Official Information Act, found the 73-bed maternity service couldn't cope, and urgently needed another 11 beds.
For two years, staff had quickly discharged or transferred patients to try deal with demand, but services couldn't meet safe standards of care.
As well as Middlemore, there are birthing units in Botany Downs, Papakura and Pukekohe. Births within the district have dropped to about 18 a day, but cases are increasingly complex.
From 2014-2017 women turning up in labour "unbooked" and with no antenatal care rose from 88 to 118 a year, and 245 more women had cesareans. More than one in 10 pregnant women now have diabetes.
The DHB review listed "contributing factors" to incidents (such as the baby stillbirths and deaths) as including: lack of oversight for women with complex conditions; too few medical and midwifery staff in busy times; poor triaging and limited staff and bed space, including to allow extra elective C-sections at short notice or urgent inductions.
"Over the last year, maternity services has seen an increase in the number of [serious harm events] where resources and capacity have contributed to the adverse outcome."
Ministry of Health standards require 72 hours of post-birth care for certain women, such as those with difficulty breastfeeding. In 2017, 1170 such patients were instead sent home from Counties facilities within two days.
After the review, the DHB 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.
Some women with babies in the neonatal unit will move in phases to another ward, freeing up 22 beds on the maternity floor. A new women's health building is about five years away.
Apologies were offered to affected families, and some receive ongoing support. Women's health leadership is being "increased and strengthened" as part of a wider review of DHB senior roles.
Dr Jeff Brown, the NZ president of the Royal Australasian College of Physicians (RACP), which represents medical specialists including at Counties, urged the DHB to work with clinicians to ensure safe care.
"We cannot continue to place parents, whānau and newborns in precarious services," Brown said.
"A drive for early discharge and transfer where resources are under pressure can signal wider systemic issues, may run counter to maternity guidelines, and put mothers and babies at risk."
More than a third of Counties Manukau residents are among the country's most socioeconomically deprived.
Sue Claridge, of the Auckland Women's Health Council, said poverty and large Māori, Pasifika and migrant populations made the failures particularly troubling.
"If you have resourcing issues coupled with a more vulnerable population there's going to be potential for disaster ... mums and their newborns are some of our most vulnerable citizens. They often have the smallest voice - the least ability to demand something better."
Brenda Hinton, spokeswoman for the Maternity Services Consumer Council, an advocacy group for women and families, said demand was linked to wider social issues such as unaffordable housing. Medical trends, such as rising cesarean and induction rates, contributed.
"The pace of change - the ability to respond to things - in our health structures is just way too slow ... I'm concerned these deaths won't be the last."
Jenn Hooper, founder of support group Action to Improve Maternity, said it was heartening the DHB was working to fix complex problems. However, she questioned whether there were unreported cases.
"If the investment isn't there, it can have real potential to go hideously wrong and lead to lifetime disability, or death."
Like other DHBs, Counties has little spare money and competing demands. Last month the Auditor-General noted the worsening financial position of DHBs, writing: "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)."
Middlemore's maternity issues are long-standing. An independent 2014 report urged the DHB to fix its poor service for Māori and Pacific women by addressing staff shortages.
The same message came two years earlier, in another review ordered because South Auckland's newborn death and stillbirth rates were the country's highest. It found that could largely be explained by underlying health and social conditions, but warned, "it is essential that objective safe staffing levels are identified as a matter of priority".