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An independent inquiry into the death of a first-time mother during childbirth has found tired and overworked staff "impacted negatively" on her care, and death was preventable.
Renee Wendy Bayliss died within hours of giving birth in January after medical staff at Auckland City Hospital failed to stem excessive bleeding from the delivery of her daughter.
Baby Allix survived but two investigations were launched to pinpoint the chain of events which led to her death.
Dr David Sage, chief medical officer for the Auckland District Health Board, accepted the hospital "failed" Renee, 33, and her death was preventable.
"This was an upsetting case and I would like to express my deepest sympathies to the patient's family.
"I hope this investigation will provide them with further understanding of why this happened and the assurance we are doing all we can to ensure an event like this will not happen again."
Renee was admitted to hospital on December 31 with pre-eclampsia, a serious condition that can involve high blood pressure. Her placenta was also found to be at risk of causing problems, including bleeding after birth.
Her police officer partner Nick Blackley told the Weekend Herald she specifically asked for compatible blood be put aside for her.
Renee lost about 2.5 litres of blood while giving birth early on January 26 and - although the registrar also asked for compatible blood - there was a long delay.
She lost consciousness at 6am because of blood loss. The first unit of blood was given 12 minutes later - 32 hours after she asked for it to be set aside.
The review panel for the independent inquiry included an obstetrician, anaesthetist and midwife, as well as a specialist in how sleep cycles affect human performance.
They found the maternity unit was "extremely busy" when Renee was in labour, with several high-risk obstetric cases. Although not rare, that meant the lead clinicians looking after her changed on "multiple occasions".
The panel commended National Women's Health Services for making changes since Renee's death, but it made a further 10 recommendations including:
A review of the care and management plan for all pregnant women.
Better communication protocols between medical staff.
Better communication between blood bank and medical staff.
An earlier internal inquiry triggered a raft of changes that will affect all pregnant women at the hospital. Some have already been made, including:
A new process for obtaining emergency blood.
Improving handover procedures between staff.
Checking all pregnant women for risk of postpartum haemorrhage.
Sage said that the board extended its sympathy to Renee's family but added there were not systematic problems in the maternity service.
Nick Blackley's lawyer, Antonia Fisher, said the family found it hard to understand how Rene could have died in childbirth, while in theatre, in a major hospital given staff were aware of her condition but did not want to comment further.
