A young couple made a gruelling decision to terminate their first pregnancy at 25 weeks
after a midwife failed to read two earlier ultrasounds showing significant abnormalities.
If the scans had been read by the midwife, problems with the pregnancy would likely have been picked up four weeks earlier.
Instead, the woman was forced make a decision on an abortion much later than normally advised. Abortions after 20 weeks are very uncommon (0.4 per cent in 2018), according to the Ministry of Health.
Today, the couple won an apology from the midwife after an investigation by the country's health watchdog, Health and Disability Commission (HDC).
It comes at least two years after the tragic loss.
Deputy Health and Disability Commissioner Rose Wall criticised the midwife for failing to read the results of two ultrasound scans, saying it was "a basic requirement of any health professional".
Despite the woman repeatedly requesting information from the midwife about these reports, she was met with unfulfilled promises or silence from the midwife, the report said.
In the report, a text from the woman to the midwife said:"I should have been referred to a specialist four weeks ago after my 16-week scan ... I had specifically asked you twice about the radiology report and didn't get a reply," a text from the woman to her midwife said.
Wall said this case highlighted the importance of communication between a woman and her LMC midwife, and of junior midwives recognising their limitations and ensuring their
caseload is appropriate for their experience.
An independent expert midwifery adviser told HDC during the investigation that a midwife was expected to read and acknowledge every result.
The deputy commissioner said the midwife has since reflected on these events and decided to stop working as a LMC midwife, and had provided a written apology to the woman.
Her report also recommended that should the midwife recommence her work that she receive all scan and laboratory reports electronically, set up a shared system
of electronic notes for midwives in the practice and introduce a system of "tasks to do".
The HDC decision comes after the Herald on Sunday revealed a traumatised mum who is haunted by the sound of her precious baby boy dropping on a hospital floor at birth before taking his final breath 90 minutes later.
And earlier this month, a father who lost his wife during childbirth and their newborn daughter four days later pleaded for an investigation into their sudden deaths.