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Independent assessors Ernst and Young found the strategy's nine key actions were not defined in detail, not formally tracked, and nor was it set out what entailed those actions being done.
Governance was informal, unclear, inconsistent and lacked accountability, while project management "lacked the level of maturity required for a project of this scale".
The review sought to better target provision of maternity services across the whole SDHB region, and proposed creating maternal and child hubs in several towns - controversially so in Lumsden, Te Anau and Wanaka.
However, what a hub actually was and did was "vague and undefined" and had led to mixed or misinformed messages and a "misalignment of expectations", the report said.
Adding to the shambolic roll-out of the strategy, key roles remained vacant at critical periods, and the strategy's project management role had been vacant since February.
That resulted in equipment which was meant to be in hubs not arriving before they opened, no common agreement between the DHB and the communities about what a hub was, and people intended to be co-ordinating the hubs not knowing that was what was expected of them.
Issues with the early stages of the strategy meant there was a risk that key decisions due in the next 12 months, such as where the Central Lakes primary maternity facility would be sited, would not be delivered as planned.
SDHB chief executive Chris Fleming said the review "reflects the challenges we have faced implementing the system of care," as well as achievements made.
"We accept the findings however that we did not adequately anticipate or plan for the scope of changes required, by ensuring we had sufficiently robust project management structures in place.
"We particularly acknowledge that the transition to a hub in Lumsden has been a concern for the rural Southland community, and there was more we could have done to ensure this change went more smoothly."
The board's decision to close Lumsden's primary birthing unit, the Lumsden Maternity Centre, and replace it with a hub was outside the review's terms of reference.
Carrie Adams, a trustee of centre owners the Northern Southland Medical Trust, said the report findings supported the trust's arguments against the change to a hub.
"It was felt [by the SDHB] our concerns were not substantial or legitimate, but this report vindicates them," she said.
"The big question is now what does this report mean, and will the health select committee act on it?"
Clutha-Southland National MP Hamish Walker, who took a petition to Parliament to try to save the Lumsden centre, said the review should have been wider.
"At the direction of the SDHB the reviews have only been able to look into the new, failed, downgraded hub model.
"Even then the two reviews have still revealed multiple failings in the roll-out of the hub model."
• Seven of nine key actions started, one not begun, one completed.
• Poor governance framework; project management unco-ordinated.
• Communication and change management unclear.
• Uncertainty what a "maternity hub" is.
• Telemedicine oversubscribed, but inconsistent delivery of service.
• Improve communications.
• Have visible, pro-active champions for strategy.
• Establish independent chair for stakeholders group.
• Co-design hubs with communities.
• Visit each facility rather than do business by email.