A midwife has been sanctioned by the health watchdog for a series of failures that led to a young woman losing her baby.
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Deputy Health and Disability Commissioner Rose Wall said the woman, aged in her late teens, lived rurally, and chose a midwife who was outside her area, because she had cared for other whānau members.
The midwife did not keep accurate records throughout the woman's pregnancy and did not follow up warning signs of possible complications, Wall said.
When the woman went into labour, the midwife assessed her over the phone, but did not recommend she be seen in person.
Finally the woman was rushed to hospital, but the baby had died.
The woman said she was still impacted by the loss of her baby and hoped better measures were in place to prevent it from happening to other hāpū māmā in the future.
"My partner and I were looking forward to bringing our baby home. We had prepped her room, bought everything she would ever need, furniture, clothing etc."
"Our drive to the hospital was exciting and we couldn't wait to share her with our big whānau." she said.
"We are still impacted by the loss of our baby. Despite what happened, I sincerely hope that no other 'hapū māmā' including her whānau will ever have to experience what we have and that all the measures are taken to ensure the health and safety of mother, baby and whānau are upheld and respected in the future."
The report stated in the final weeks of her first pregnancy, the woman developed oedema, headaches, and elevated blood pressure - symptoms of a pregnancy complication called pre-eclampsia.
The midwife having not visited the woman, did not realise the seriousness of the complications and failed to request a blood test for the woman or perform a urine analysis.
"When the woman was in labour, the midwife assessed her condition by telephone but did not recommend an in-person assessment, although it was warranted. The woman was then rushed to hospital. Tragically, her baby had died."
"Had this occurred, the symptoms of pre-eclampsia, intrauterine growth restriction, and reduced fetal movements may well have been detected sooner," Wall said.
The midwife responded to the observations stating she told the woman all visits would need to take place at their clinic, primary consultations would be over the telephone and if the woman had to go to the hospital there was a chance the midwife would not make it in time so the woman would need to consult hospital midwives instead.
The midwife ran their own personal practice, which was an hour's drive from the woman's home.
Having worked with the woman's whānau on prior births, the midwife believed that the whānau likely believed everything to be normal.
The midwife said they thought they had provided the best possible care at the time but upon reflection had realised there were some regrettable decisions - but they did not know if this would have saved the baby.
"Obviously in hindsight and reviewing my practice pre-eclampsia bloods would have given a better view on what was going on internally.
"My actions were not proactive enough and I have considered the desire for her to homebirth may have clouded my judgement and caused my inaction.
"My deepest aroha for [Ms B], her partner, and her whānau for the loss of [the baby]. A precious daughter, mokopuna, cousin, and niece."
Wall recommended the midwife provide a written apology to the woman and her whānau, undertake training on pre-eclampsia in pregnancy, and documentation as well as the Growth Assessment Protocol.