An investigation into the care of a woman and her identical twin babies has found there were systemic problems within a district health board.
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The woman had an ultrasound when she was 28 weeks pregnant. While problems were noted by the sonographer, the radiologist did not document them in his report, nor take any follow-up action.
Three days later, the woman required an urgent Caesarean section, after she arrived at the hospital with abdominal pain.
She was found to have Twin-to-Twin Transfusion Syndrome - a prenatal condition in which twins share unequal amounts of the placenta's blood supply.
Several difficulties presented themselves as the woman was giving birth.
Theatre staff were unaware there were two babies being delivered, and were in a small operating theatre where they had to locate a second resuscitaire.
The first twin was born floppy with no heartbeat and required immediate resuscitation. Three attempts were made to intubate the first twin, but only on the third attempt did they realise the oxygen cylinder was switched off.
Then, when the cylinder was turned on, the baby's oxygen saturations did not rise to the expected level. That was because the endotracheal tube - the tube which is placed through the mouth into the windpipe - being used was too small for the baby.
When the tube was changed, the baby's oxygen saturations did rise to the expected level.
Deputy Health and Disability Commissioner Rose Wall criticised the radiologist's initial report, as well as the fact a paediatric consultant was not involved straight away for an urgent or emergency birth.
"I consider that at the time of the incident, [the DHB] had several systemic issues," Wall said.
"This affected the care provided to [the woman] and [twin 1]."
Since these events, the DHB has commissioned an external review of its maternity services, and taken a number of steps to improve its systems.
The DHB apologised to the woman, and took steps including increasing staffing, reviewing equipment, and implementing Care Capacity Demand Management in Maternity.