Newborn died from pneumonia after discharge from hospital at 6 hours old

A baby who died at home the day after he was born would likely have survived if he had still been in hospital, a coroner's report says.

By Rowan Quinn of RNZ

The report calls for sweeping change to fix deep, engrained shortages and a lack of funding across the country's maternity service.

Baby Remedy and his mother, who is described as vulnerable, were discharged from hospital six hours after he was born.

He was 32 hours old when he rapidly deteriorated and died from acute pneumonia in June 2024.

An expert said the early discharge made the first 24 hours of his life unnecessarily complicated and his mother had limited resources to call on when his health suddenly changed.

Coroner Alison Mills said opportunities to support the mother through pregnancy were lost and the case highlighted the system-wide lack of staff and beds in the country's maternity service, particularly for those focused on Māori whānau.

Remedy's mother, whose name is suppressed, was 19 when he was born and had a seemingly uncomplicated birth at Waikato Hospital.

It was not uncommon for low-risk babies to be discharged the same day but Remedy's mother had wanted to stay the night.

She told Coroner Mills that staff said there were not enough beds so she left.

She was too tired to drive home to Auckland so stayed the night with Remedy's father, who lived in Hamilton, and went home the next day in time for a midwife appointment.

Remedy had seemed well when he was discharged - and again during the midwife visit - but a few hours later his mother became worried about his breathing.

On the advice of her own mother she put him to bed.

The first time she checked on him he seemed fine so she went to have some food and look after her one-year-old. When she went back again, he looked blue.

She called an ambulance and did CPR but Remedy could not be revived.

An expert helping the coroner, Dr Callum Gately, said Remedy likely died from sepsis as a result of pneumonia contracted during his birth.

The disease could escalate very quickly, he said.

But it would likely have been picked up and treated if Remedy had still been in hospital.

Gately said even though Remedy seemed healthy, he and his mother's social situation should have been considered in the discharge planning.

"He noted that [she] was a vulnerable young woman, and this was an important opportunity to provide extra wraparound support or at least offer it," Coroner Mills' report said

Gately said that after driving back to Auckland the day after giving birth, the mother was managing the care of her one-year-old and a newborn.

"This period of time would have been extremely challenging, balancing the needs of two babies by herself," the report said.

"It would have been difficult making assessments and judgements on the health needs of a newly born infant with limited support on the tail end of a fatiguing 48 hours."

A staff member told the coroner the midwives had been looking for a primary birthing centre for her to go to but that she chose to leave.

Both the woman and her mother say they were told there were no beds in the hospital.

She had not had a midwife or medical care during her pregnancy, apart from one scan at 32 weeks.

If she had been engaged with a kaupapa Māori antenatal service, it was highly likely she would have been empowered and prepared with strong relationships to call on when the unexpected occurred, Gately's evidence said.

Coroner Mills was not critical of individual people caring for Remedy and his mother.

The community midwife who had delivered him in hospital went to great lengths to find a midwife to pick up their care in Auckland, calling around several.

When she found one, she made sure Remedy's mother knew to expect a visit the next day, and to call if she had not heard from them.

"I agree with Dr Gately's comments that Remedy's death highlights the excellent work that individuals do in an under-resourced and stretched maternity service," the coroner said.

The young woman's mother had also travelled to hospital to support her in labour, and had been at her house the next day helping, along with her grandmother.

"The tragic outcome was no fault of [Remedy's mother] or any individual healthcare provider," the corner said

"The systemic lack of maternity beds, under-resourced teams and engrained paucity of maternity services which are culturally safe for many Māori wāhine, pēpi and whanau sadly led to missed opportunities to support this whānau through pregnancy and the perinatal period."

Remedy's mother had been known to Oranga Tamariki since she was a child because of her exposure to violence, alcohol and drugs.

More recently, the agency had been involved during her pregnancy because of violence against her at the hands of the father of Remedy and their other child.

The coroner noted the agency made no attempts to discuss her pregnancy and to ensure that she and Remedy were receiving the appropriate antenatal care.

Coroner Mills said it was difficult to make recommendations to address an "entrenched and systemic problem".

"However there is a real need for these issues to be addressed. It requires a significant increase in resources, funding and cultural change within institutions," she said.

She noted Māori babies and mothers were more likely to die or suffer serious complications around birth and were less likely than pākehā to have consistent antenatal care.

There needed to be more Māori and Pacific midwives but also better cultural training for everyone in the maternity system, Coroner Mills said.

She noted the funding for a 2021 programme Te Ara ō Hine — Tapu Ora, aimed at increasing the number of Māori and Pacific midwives, would cease at the end of this year.

"In light of the ongoing shortage of Māori and Pacific midwives and the impact this has on access to culturally safe midwifery care, I recommend that Te Whatu Ora / Health NZ continue to resource initiatives such as the Te Ara ō Hine — Tapu Ora programme and continue to explore other initiatives to increase the number of Māori and Pacific midwives," she said.

Several agencies involved in the case had responded to the coroner's initials concerns and they were outlined in her report.

Oranga Tamariki had identified gaps in how it dealt with the case and made changes, the report said.

It had strengthened its oversight of cases where unborn or vulnerable babies may be involved, and would work to better consider family histories in making decisions.

Te Whatu Ora Waikato said it supports improving cultural safety training in maternity care and said it would review its policies around transfer to a primary maternity facility after birth.

The Ministry of Health told the coroner it agreed with her recommendations and would continue to try to improve equity in the health system and expand programmes to improve cultural safety.