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An investigation into the care of a woman who bled to death after giving birth to her first baby found medical staff were slow to get blood for an emergency transfusion and there was not enough to replace what she had lost.
Renee Wendy Bayliss, 33, died within hours of childbirth at Auckland Hospital in January after staff were unable to stem excessive bleeding in the delivery of her daughter.
Baby Allix survived, but the Auckland District Health Board (ADHB) launched an internal inquiry to pinpoint how she died, sparking a raft of changes that will affect all pregnant women at the hospital.
A second, independent review has been ordered by the ADHB and a complaint has been laid with the Health and Disability Commission.
The ADHB refused to release the full internal report under the Official Information Act, citing privacy issues, and sent a three-page summary.
But sources confirmed medical staff were slow to order blood for an emergency transfusion and when it did arrive, there was not enough.
Some changes have been made as a result of the inquiry, including:
* A new process for obtaining emergency blood.
* Improving handover procedures between staff.
* Checking all pregnant women for risk of postpartum haemorrhage.
* A new pre-operation list for theatres.
* Ensuring all antenatal admissions have a clinical "problem list" completed within 24 hours and updated throughout the pregnancy.
* A "massive transfusion protocol" to be developed and implemented for haemorrhaging during childbirth.
ADHB chief medical officer Dr David Sage said the board extended its deepest sympathy to Bayliss' family but made clear there were not systematic problems in the maternity service.
"Thousands of women are successfully treated each year at the ADHB following childbirth. This is a tragedy for all involved but I am confident that it is an isolated case," Sage said.
Renee had been an inpatient at the hospital since New Year with high blood pressure, a symptom of pre-eclampsia, which increases the risk of a postpartum haemorrhage.
Through the ADHB, her family asked not to be contacted about the report and for no specific details of the incident to be released.
She was farewelled by her police officer husband Nick Blackley, family and friends at Auckland's All Saints Chapel in February.
Wendy Bayliss, Renee's mother, paid tribute to her fun-loving daughter who had always wanted to be a mum.
"I'm just so glad her wish came true and that she got to spend some time with her beautiful daughter."
Service celebrant Julia Cameron said the family wanted to celebrate Renee's short life, but their grief and love were mixed with anger because there were unanswered questions over her death.
Acting Health and Disability Commissioner Rae Lamb confirmed a complaint had been laid but a decision whether to investigate further had not been made.
Maternal deaths are monitored through the Perinatal and Maternal Mortality Review Committee, set up in 2005 to review the deaths of newborn babies and mothers.
The committee will review Renee's death and is understood to be investigating the deaths of 12 women during pregnancy or soon after childbirth in 2006. Up to half were caused indirectly, such as a pregnant mother being killed in a car crash.
