All that said, the evidence is damning: A lack of oversight for women with complex conditions; too few medical and midwifery staff during busy times; poor triaging; and limited staff and bed space, including to allow extra elective caesarean lists at short notice or urgent inductions.
Staff tried to cope over the past two years by quickly discharging or transferring patients, but services couldn't meet safe standards of care. Babies died when they could have been saved, alive now in their mothers' embrace.
This has occurred over too long a period of time, as Sue Claridge of the Auckland Women's Health Council says, to some of our most vulnerable people. There is no excuse for this nation to not provide any woman with world class maternity care. It is clear the women of Counties Manukau were let down, and so were the staff at the Counties Manukau District Health Board.
Maternity staff asked management for help, but only some budget requests were signed-off. Counties Manukau DHB leaders now say context wasn't given and they didn't understand how bad things were.
However, we now know district board executives met with maternity leaders 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", with workers concerned about "capacity, model of care and staffing". A September 2018 review found the 73-bed maternity service couldn't cope, and urgently needed another 11 beds.
The DHB has now launched both one 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 and babies in the neonatal unit will move in phases to a general ward at Middlemore, freeing up 22 beds on the maternity floor. A new women's health building is about five years away.
These remedies should have been under way years ago. It is now clear staff tried to cope over the past two years by quickly discharging or transferring patients, but services couldn't meet safe standards of care. Babies died when they could have been saved, alive now in their mothers' embrace.
No, this should never have happened, and it should never be allowed to happen again.