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A pregnant woman's doctor should not have sent her home with abdominal pain and signs of infection, an investigation has found.
The consultant obstetrician and gynaecologist breached the woman's rights when he sent her home despite showing red-flag symptoms, Deputy Health and Disability Commissioner Rose Wall said.
The woman who was 33 weeks pregnant went to a public hospital in 2021 with abdominal pain and her waters broken. She then received treatment and medication before being discharged.
When she went to a scheduled scan four days later, her discharge had turned green and her pain remained. Instead, she was sent home with an induction booked two weeks later.
She returned the next day as contractions had started, but her baby died in utero and she delivered them vaginally.
Wall said she was critical that the woman was discharged with ongoing abdominal pain and green discharge.
"Chorioamnionitis can present subtly and develop rapidly. This would have placed the wellbeing of her foetus at risk," she said.
"For this reason, I would have expected Dr C to arrange for [the woman] to be admitted to the maternity unit for full investigations to be undertaken.
"This did not occur."
In the commissioner's report, the woman's doctor said she should not have been discharged and should have been sent to the Maternity Unit for further assessment.
"I still cannot think of any human factors that might be relevant as, although they would not have excused my mistake, they might have explained why it occurred. Their absence is a concern to me, as I really would like to understand why I made such a basic mistake," he said.
"I cannot reverse it but would like to have better confidence that I wouldn't make such a mistake again."
Wall recommended that he used this report as a basis for a case study presentation at Health NZ Te Whatu Ora, focusing on the breach identified, the decision or actions taken, the result and the action that should have been taken.
She also recommended that Health NZ update its obstetric orientation to stress the importance of assessing patients who might have an infection.