The tragic string of decisions that left a mother-of-seven and her newborn baby dead three days after giving birth - as her broken partner says 'I've lost my soulmate'
Emerald Waiari Tai , 27, and her newborn son Tanatui Samuels were found dead at their home in West Auckland on March 18 last year three days after she gave birth
A young mother who died alongside her newborn baby three days after giving birth self-discharged from hospital despite staff suspecting she had an infection, a report has found.
Mother-of-seven Emerald Waiari Tai, 27, and her newborn son Tanatui Samuels were discovered dead at their home in West Auckland, New Zealand, on March 18 last year.
Ms Tai's partner, also named Tanatui Samuels, discovered the pair unresponsive in bed and called emergency services, who pronounced the mother and son dead.
Ms Tai died from sepsis after contracting an infection after giving birth although it was unclear how she got the infection, the New Zealand Herald reported.
Her newborn son also had sepsis but it is understood Ms Tai may have fell onto her child after she died with 'unsafe sleeping' contributing to his death.
The coroner is still investigating the deaths of the mother and son but the Auckland District Health Board carried out their own investigation into patient care.
The report has not been made public by the ADHB but the family provided a copy to the New Zealand Herald.
The report revealed staff suspected Ms Tai had an infection and described the early symptoms of sepsis after taking a swab from the mother.
Ms Tai and her partner Tanatui Samuels at a restaurant. Mr Samuels wrote a heartbreaking update following his wife's death, saying how much he missed her
Ms Tai and one of her six surviving children, who are being looked after by Mr Samuels. Ms Tai's mother said Mr Samuels was deeply grieving while looking after the kids
But her case was not escalated as the condition can be 'often masked by the normal physiology of pregnancy' and 'challenging to recognise', the report said.
Ms Tai later signed a 'discharge at own risk' form, leaving the hospital less than 24 hours after giving birth.
However, staff did not record her correct home address and the community midwife did not receive a complete handover, the report said.
A midwife went to the address Ms Tai had provided at a previous medical appointment and left a standard 'sorry I missed you form' at the incorrect location.
The midwife 'had no reason for concern' about the 'unsuccessful visit' because they had not been provided with information about the early discharge.
The report has 10 recommendations that the ADHB has either already implemented or will aim to by June.
The recommendations include establishing better sharing of information between social agencies and providing resources to mothers after giving birth, helping them to identify 'signs of sepsis after discharge'.
ADHB director of women's health Dr Rob Sherwin acknowledged the 'tragic loss' of the mother and son and offered 'heartfelt condolences' to the family.
The Auckland District Health Board carried out an investigation into Ms Tai's patient care with a report by the coroner yet to be finalised
'What we can say is that the individual review into Emerald's care highlighted some areas where our systems were not set up to enable equitable health outcomes for all of our women, and for that we are deeply sorry,' Dr Sherwin told the Herald.
Ms Tai's partner Tanatui Samuels wrote a heartbreaking tribute online following her death, saying how much he missed his wife.
'Me and the kids love you and miss you too much,' Mr Samuels wrote.
'Our love to you is painful cause your presence is not around anymore and nothing will ever be the same because I have lost the most beautiful woman in the world.
'I'm trying my hardest to look after the babies... I miss you my love.'
Ms Tai is survived by her partner and six other children - aged 12, nine, eight, three, two and one.
Her mother Susan Fa'amoe said 'Tana has lost his soulmate' and 'I have lost my daughter and my grandson who I never got to meet'.