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A service set up to provide consistent maternity care for Whanganui women has been reviewed following the death of five babies and serious harm to two more.
The review of the Regional Women's Health Service has revealed numerous failings in MidCentral District Health Board's leadership and coordination in relation to the service.
Meanwhile, a report of the review said Whanganui District Health Board has adapted well to the service.
The review was called for in October after seven "serious adverse events", which led to two foetal deaths, three newborn deaths, and newborns with "significant morbidity".
Six of the events happened at Palmerston North Hospital while one happened at Whanganui Hospital. The events happened between December 2014 and August 2015.
The service was an initiative between Whanganui District Health Board and MidCentral District Health Board, and MidCentral has been strongly criticised in the report.
The two health boards joined their maternity services in 2013 to create the service in response to uncertainty around obstetric cover in Whanganui Hospital in the two years previous. The report said there was "sufficient" cover at the moment, "but it remains tenuous".
The chief executives of both boards called for the review, which revealed there was confusion among MidCentral staff around responsibility and accountability.
It said there were "differing philosophical perspectives between clinical leaders", resulting in difficulties at leadership level.
It also identified a "lack of timeliness" in reviewing adverse events due to a lack of co-ordination, poor teamwork, a disorganised clinical setting, and a problem with lead maternity carers transferring the care of women to hospital staff, which increases staff's workload "unpredictably".
One of the serious adverse events at MidCentral was not reported to the Health Quality and Safety Commission until about three-and-a-half months after it happened.
The rollout of a new electronic maternity record in July also placed "unexpected pressure" on the service.
The report said if Whanganui health board could not recruit and maintain adequate obstetric cover, they would have to rely on locums, which created risk because temporary staff were not familiar with the unit, policies and staff.
"Overwhelming feedback" from staff and management at both health boards showed many felt there had been little to show for investment in the Regional Women's Health Service, and it had become "very complex".
Committees and groups had been formed that appeared to replicate current groups within each health board.
Participants in the review process felt they were "drowning in paperwork" and labelled the project "very bureaucratic". "In light of the failure of the RWHS to develop into a fully integrated service, it is recommended that the project be reviewed and a less complex process developed to enable reliable obstetric cover for Whanganui DHB to be maintained," the report said.
Whanganui chief executive Julie Patterson said it would be "business as usual" for the service in the immediate future, but said the two boards would be "considering the arrangements".
"The one finding relating to Whanganui is that if we cannot recruit sufficient permanent obstetric staff, we would need to rely on locums which may not provide continuity of care for our women," Mrs Patterson said.
"With this in mind, Whanganui and MidCentral DHBs will work together to address the recommendation that our two organisations develop a memorandum of understanding or similar arrangement, that lays out clearly for staff and the community steps to take in the event of suspension of services due to staff shortages."
MidCentral chief executive Kathryn Cook said the families affected by the serious adverse events had been kept informed of the review.
"In light of the recent tragic events, we need to be confident that we are doing all we can to ensure that the mothers and babies receive safe and effective care," she said. "Each event was a family tragedy and we offered our regrets to the families at the time."
A copy of the Regional Women's Health Service review can be found by clicking http://www.contentedcms.co.nz/clientfiles/whanganui-district-health-board/files/review-of-rwhs-maternity-service-report.pdf or by heading to the Whanganui District Health Board website.