“Irreparable Harm”: Health NZ Slated After Multiple Errors Led to Stillbirth in Auckland
By Rowan Quinn • Lions Roar Aotearoa Health Bureau
AUCKLAND, NEW ZEALAND (Tuesday, January 27, 2026) — A devastating report from the Health and Disability Commission (HDC) has revealed how a “stretched” Auckland health system failed a mother whose baby was stillborn after critical risk factors were repeatedly overlooked.
The report, released today by Deputy Commissioner Rose Wall, details a series of clinical failures by Health NZ Waitematā (Waitākere and North Shore hospitals) in 2021. The mother, who was 38 weeks pregnant, told the commission that “human errors ultimately led to the death of my baby” and that her pleas for help were simply not heard.
⚠️ A Chain of Overlooked Risks
The HDC found that multiple opportunities to save the baby were missed during a pregnancy marked by high-risk indicators that were never properly managed.
- Uterine Fibroid: The woman had a large fibroid—a growth that requires extra monitoring—but no plan was ever made to track the baby’s growth effectively.
- The Delayed Scan: Despite asking for an ultrasound from 28 weeks, the woman was not referred until 37 weeks. It then took 10 days to receive an “emergency” scan.
- Contradictory Results: The radiologist’s report contained conflicting information, stating in one section that amniotic fluid was normal and in another that it was dangerously low.
- Plotting Errors: Hospital staff incorrectly plotted the baby’s weight, failing to recognize the infant was “Small for Gestational Age” (SGA).
🏥 The Waitākere Hospital Failure
The situation reached a crisis point when the woman presented at Waitākere Hospital (diverted from a full North Shore Hospital) due to reduced fetal movement.
- Abnormal Heartbeat: Monitoring showed the baby’s heart rate dropped and recovered slowly—a major red flag—yet the woman was sent home.
- The Fatal Return: She returned the next day when movement stopped entirely. A registrar performed an ultrasound and confirmed the baby had died.
- Systemic Pressure: The report noted the maternity unit was overwhelmed. The senior obstetrician on duty wasn’t even aware that patients were being diverted to their unit until they began arriving.
💬 “A Deeply Personal Tragedy”
In a heartbreaking statement to the commission, the mother described the trauma of advocating for herself and being ignored.
“I did everything I could to raise concerns and advocate for my wellbeing and that of my baby, but I was not heard… This has not only been a clinical failure but a deeply personal tragedy that has left lasting emotional and psychological damage.”
📊 Findings: Health NZ Waitematā Responsibilities
| Error Type | Specific Failure |
| Monitoring | No action taken regarding the large uterine fibroid. |
| Communication | Midwife’s warnings were not passed to hospital staff. |
| Clinical Review | Failed to recognize low amniotic fluid was abnormal for a “normal-sized” baby. |
| Documentation | Incorrectly plotted fetal weight; ignored abnormal heart scans. |
| Staffing | Reliance on a junior doctor to assist an overwhelmed senior obstetrician. |
🏥 Health NZ Response
Brad Healey, Director of Operations at Waitematā, expressed deep regret and “sincerest apologies” to the patient. Health NZ fully accepts the findings and has implemented several process changes, including:
- Mandatory escalation of abnormal findings.
- Improved contingency plans for hospital diversions.
- Refresher training on identifying Small for Gestational Age (SGA) infants.
