Special report: ‘He wasn’t given a fair chance’ - Why a newborn’s death rings alarm bells for our maternity system

Tuesday, 28 April 2026

Emma and Paul Newlands’ son lived for less than a day, after his distress before birth wasn’t recognised by hospital workers on an inadequately staffed shift. Other babies have died amidst similar staffing problems. Nicholas Jones investigates.

Content warning: This story is about baby death and might be distressing to some readers.

Reuben Newlands was a fighter, denied a fighting chance.

His parents, Emma and Paul, endured infertility and IVF - which they were told had a slim chance of success - and Reuben’s was the only embryo that was viable.

After the couple, both teachers in the Bay of Plenty, received the thrilling news that Emma was pregnant, blood tests showed hormone levels weren’t rising normally, indicating an ectopic pregnancy or looming miscarriage.

At her eight-week scan Reuben’s heartbeat was so faint that Emma was told the pregnancy was unlikely to progress.

Reuben, however, defied the odds, and by 20 weeks had grown into the epitome of health.

Emma was booked for an induction on April 20, 2022 but sometime in the early hours of April 19, she likely suffered a concealed placental abruption.

This happens when the placenta partly or completely separates from the uterus wall, which cuts the baby’s supply of oxygen, and causes internal bleeding in the mother.

In the morning Emma - now 40 weeks and two days pregnant - couldn’t feel Reuben moving, and met her backup midwife at Tauranga Hospital.

Contact the reporter: nicholas.jones@stuffdigital.co.nz

Walking from the car, she pressed her stomach and felt Reuben inside her for the last time - over the course of the day her abdomen hardened, and became sensitive to touch.

At 9.26am cardiotocography (CTG, and also called electronic fetal monitoring) began. This used sensors placed on her abdomen to monitor the baby’s heart rate and Emma’s contractions.

Reuben's abnormal heartbeat pattern indicated fetal distress. This, combined with his lack of movement, should have led to an urgent caesarean section, a hospital investigation would later find.

Emma and Paul were relieved when Reuben’s heartbeat came through on the monitor. However, their backup midwife realised he was in trouble.

She didn’t relay her worry to them, but called for a doctor, who she spoke with in a corridor before the examination.

Emma and Paul say the obstetric registrar - who later told the Health and Disability Commissioner (HDC) she made her notes retrospectively because the shift was “incredibly busy” - only briefly touched her abdomen and checked the CTG, before telling them Reuben was likely sleeping.

At the time, the couple were reassured. The doctor planned another review in 30 minutes, but was pulled into an emergency and didn’t return, or ask another staff member to complete it.

Health NZ would later disclose there were three emergencies that day, two staff members had called in sick, and concern over staffing levels and capacity in the maternity and delivery suites had triggered a code yellow and later orange alert. It said the maternity service had a deficit of nine full-time midwives.

Emma became increasingly disorientated as she bled internally. Their backup midwife - young and near the start of her career - repeatedly left to fetch help, without success.

Paul and Emma were anxious but also reassured by the lack of urgency shown by hospital staff who eventually checked on her after midday, including another doctor who booked a category two caesarean - for cases that aren’t immediately life-threatening.

Reuben was pulled from Emma’s womb at 2.35pm, weighing 3.83kg, and covered in blood, which he had also inhaled into his lungs and stomach.

Emma didn’t smile when she heard the words “here’s your baby boy”, but waited for him to be lifted above the blue curtain blocking her from seeing the operation.

That moment never came. Instead, Reuben was rushed away by doctors. In the following hours Paul shuttled between his wife’s room and the Neonatal High Dependency Unit, bringing her increasingly dire updates.

Emma’s agony of being separated from her baby ended when it became clear he wouldn’t survive, and she was wheeled to him.

Reuben Ayson Newlands was taken off mechanical ventilation, and died on his mother’s chest, aged 22 hours.

A subsequent adverse event review by the hospital concluded a delay of more than five hours delivering Reuben “further compromised” him.

“Proceeding to an emergency category one caesarean section within the hour of presentation to Tauranga Hospital would have significantly improved the outcome for Reuben and may have prevented his death,” the investigation concluded.

As well as the staffing shortages on the day, the investigation found hospital staff had been missing CTG training because of “reduced staff availability”.

When Emma and Paul learnt of those failures their grief took on an uglier form.

“Reuben was nearly born dead. But he fought, as he did in the first trimester,” Emma says. “He was a true fighter, and if he was given a fair chance by the maternity ward that day he certainly could have made it.”

Other babies have died amidst staffing issues

Stuff has reviewed HDC decisions and coronial findings covering births at public hospitals and maternity centres, and found Reuben’s death is not an isolated tragedy.

Since 2016, there have been 10 other cases where a baby was stillborn or died soon after birth, with subsequent investigations identifying staffing shortages or pressure.

Staffing issues were also identified in five cases in which the babies survived, but had to be resuscitated and suffered lifelong injury and disability, including from brain damage and stroke.

In another incident, a woman died during a C-section at Middlemore Hospital that should have been done by a senior specialist, but wasn’t because no one was available.

(Health NZ told Stuff improvements had been made following the cases, which were tragedies for the families involved, but “not representative of maternity care overall - the vast majority of whānau continue to receive safe, high‑quality maternity care”.)

The numbers are highly likely an undercount - the HDC, an independent government agency, needs a complaint to be made, and takes years to make findings, meaning cases from at least the past two to three years won’t have surfaced.

Coronial investigations also have a lag time and don't cover stillbirths, and they are only notified about a minority of baby deaths.

As is usual with such investigations, generally no determination was made on whether the staffing problems caused the deaths. Rather, they were identified as factors or possible factors - among others, like errors from individuals - in substandard care.

For instance, following a 2018 case in which a baby died soon after birth at Christchurch Hospital, the HDC determined inadequate staffing had created an excessive workload, resulting in “delayed observations, a delayed diagnosis of failure to progress in labour, prolonged labour, and a delay in the C-section commencing”.

And in 2021 a girl died soon after being born floppy and unresponsive at Auckland Hospital, due to a brain injury sustained before birth, possibly from a compression of the umbilical cord. A coroner concluded she may have survived if delivered earlier, and expressed grave concerns that staffing shortages were a factor in that not happening.

The HDC recently finalised its own damning findings on what happened to Emma and her baby, which it sent to Health NZ and other agencies, “with the aim of giving further attention to the challenges facing our current maternity system”.

Commissioner Morag McDowell told Stuff the HDC had long-held concerns about the quality and safety of New Zealand’s maternity system, and a lack of progress to fix problems.

“We are aware of the pressure the midwifery workforce is under, and the capacity and skill mix of staff in obstetric units across New Zealand is a common contributing factor in complaints,” said McDowell, a former Crown prosecutor and coroner.

“These pressures intensified during the pandemic and continue amid ongoing funding and resourcing challenges.”

Experts say change is badly needed.

“Maternity is at a critical juncture,” says Professor Bev Lawton, whose work in women’s health saw her named the 2025 Kiwibank New Zealander of the Year.

“Too many babies and mums suffer preventable harm. We need to, and can, do better.”

Celebration to trauma

The month before Reuben’s due date, Paul was given a hamper of baby toys and goodies by colleagues at Suzanne Aubert Catholic primary school, and made to carry a baby doll for the day - with joking concern at how often he entrusted its care to students.

Amidst the excitement Emma was struggling, however - beset by debilitating migraines, some so severe she couldn’t speak.

One sent her back to Tauranga Hospital ED on April 18. Her request to be induced was declined, she says, and no hospital midwife checked on Reuben.

A succession of failures the next day - after Reuben stopped moving and in addition to those already outlined - have been confirmed by the hospital and HDC investigations, and include:

• The registrar who initially checked Emma discussed her plan to review her again in 30 minutes with another doctor, who agreed with it, despite never seeing the CTG trace herself. A CTG sticker wasn’t used in her notes as required. This lists danger signs, and if any are circled, the follow-up care needed is spelled out.

• When nobody returned, Emma’s backup midwife didn’t use the emergency bell or call the doctor or midwifery coordinator herself.

• No formal consultation took place after Emma was moved into an antenatal room where there were hospital midwives. After midday another doctor completed a bedside ultrasound scan, which Health NZ said was unnecessary given the CTG indicated Reuben was distressed.

• At 1.10pm the doctor who completed the bedside scan told Emma she needed a caesarean, but this wasn’t deemed urgent. Rather, it was to be done within 60 minutes - a timeframe that wasn’t met.

“When a baby is in distress, every minute counts! Reuben was born 330 minutes after arriving in the hospital in such a critical condition,” Emma wrote in her hospital complaint.

“As a mother, in such a position, you are at your most vulnerable … all you can do is go to the ‘right’ place to help you, and trust the professionals who are trained to know.

“There needs to be a cultural and systemic shift to ensure such negligence never occurs again.”

A determination for that to happen drove Emma and Paul to pursue their HDC complaint - a process they found exhausting - and to now talk publicly about what happened.

Tears are shed throughout their interview with Stuff at their Papamoa home, but especially when they recall Reuben’s birth.

Emma couldn’t remember her date of birth before the caesarean began. After she was cut open, the shocked silence in the room was only briefly interrupted when a consultant asked if she had been bleeding - there was more than 1.2 litres of blood in her uterus.

“He came out, but there was no cry,” says Paul, who was sitting by his wife’s shoulder. “I was walking over to meet him, but they were trying to resuscitate him - just pounding on his chest. He was covered in blood.

“They wheeled him off. I got taken to him - I don’t know how long later - and I sort of tickled his feet, and he did a big cry. That was the only time he cried, the whole time he was alive.”

Paul and their midwife stayed with Reuben in another room.

“I was alone,” Emma says. “I felt like I lay there for so long. I remember them trying to stop me shaking, and I just couldn’t stop - even my jaw was going, everything was shaking. I didn’t know what was happening. No one could tell me.”

Emma didn’t meet her baby until two hours after his birth, and couldn’t hold him. Her room was elsewhere in the hospital, and Paul was mostly with Reuben in the neonatal unit.

“All you want to do is be with your kid when they are born. I barely got to be there,” Emma says. “That really still messes me up. It was hell.”

‘I think about him every day’

Clinicians spoke about brain damage, then later knelt at Emma’s bed and explained Reuben was unlikely to survive.

He was the first grandchild for both sides of the family. Their parents, siblings and Emma’s grandmother were given permission (these were Covid times) to meet him.

After he died, Emma and Paul took Reuben to her parents’ place for the few days before his funeral. An ice blanket was put under his bassinet sheets.

“He was dead, but I wasn’t giving him away,” Emma says. “You wouldn’t think you would do that, but you just can’t let them go.

“Our friends got to meet him. Even to this day, my friends say, ‘I’m glad I got to cuddle him.’ That is something quite shocking, probably, for people who have never been in a situation like that. But for us, it was special, because even though they're not alive, you're still proud of them - just as proud as you are if they are alive.”

Sleep was hard to come by, and unwelcome.

“I hated going to sleep because I hated waking up,” Emma says. “You lose so much of the person that you were - every aspect of your life changes, whether it's family, relationships, friendships. You become hardened, in a way.”

Through that overwhelming grief, the couple - crucially aided by an obstetrician friend - pressed for answers and accountability.

Health NZ later apologised for failures that “were significant contributing factors in the death of your precious son”, and outlined a raft of changes since made, including a “fresh eyes review” introduced in June 2022, requiring a second person to review a CTG trace, every hour.

Sarah Nicholson, district chief midwife for Bay of Plenty, told Stuff more obstetric staff had been hired, and other improvements included an electronic clinical record system that allows CTG traces to be viewed remotely.

“We are committed to driving continuous improvement of our services … we recognise the profound distress and lasting grief experienced by Emma and Paul and their wider whānau, and we apologise unreservedly.”

Emma and Paul welcome the changes made, but worry systemic issues remain, and don’t feel there has been individual accountability.

They are appalled to learn, through Stuff’s analysis of nationwide HDC and coronial findings, that other babies have died amidst staffing issues/pressure.

CTG monitoring/response shortfalls were also an issue in three of those cases, and flagged by investigations into a further seven baby deaths, in which no staffing problems were found.

“If this interview saves one baby, then it is worth it,” says Paul. “I think about him every day.”

Last week they marked four years since Reuben’s birth and death. A wall in their home is filled with his photos, mingled with pictures of another child. Archie, his little brother, is now 2.

He talks about Reuben, and sometimes asks to hold his photo, Emma says.

“Once I asked, ‘Where is he?’ He goes, ‘Here’. I said, ‘Where is here?’ He said, ‘Stories.’”

Emma and Paul wonder what Reuben would have looked like at the same age. Would he have had the same eye colour? His brother’s happy sense of humour?

They had only hours together, to hold and gaze down at their baby boy. Emma now sees that same side profile, when Archie is asleep.

“I still sometimes go and just stare at him, and pretend he’s Reuben.

“Not because I want Archie to be him. I just wish I could see him, even one more time.”

HELP US TO INVESTIGATE

If you can help us report on this issue, contact investigative reporter Nicholas Jones by email: nicholas.jones@stuffdigital.co.nz

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