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Commissioned following complaints after changes to maternity care, particularly in Lumsden, Te Anau and Wanaka, the independent report by Ernst and Young highlighted 10 issues with the SDHB's process and made several recommendations.
It found that the SDHB governance framework for the review was "informal''. which meant clear roles had not been defined, nor what those people were accountable to deliver.
Project management, likewise, was inadequate.
"The project management practices supporting delivery of the strategy has been informal and has lacked the level of maturity required for a project of this scale.''
Key staff were not appointed _ a strategy project manager role had been vacant since February 2019 _ and the project lacked a structured communication plan.
"It has resulted in confusion (for example the definition of a "hub'' is vague and undefined), mixed and/or misinformed messages . . . and the expectation from some stakeholders in Te Anau that the hub would be a separate facility.
"There is also, to a certain extent, some disillusionment with the strategy as some stakeholders referred to long periods of silence in between communications from the SDHB and being left with the sense that no progress was being made on the actions that affected their respective locations.''
SDHB chief executive Chris Fleming said the review reflected both the challenges the SDHB had faced and its achievements.
"It also provides us with some appropriate recommendations of what we should do moving forward to learn from the progress to date,'' he said.
"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.''
The SDHB today also released a review by the New Zealand College of Midwives into four rapid births in or near Lumsden within a six week period earlier this year.
That review said that due to the "vagaries of labour'' there would always be babies born in unintended locations.
"This is not an infrequent event, especially in rural areas, however the frequency that this does occur is the measure of an accessible maternity service.''
Two of the four mothers involved declined to be interviewed for the review.
For the other two, it was found that both outcomes were unavoidable.
"Contributory factors for both incidents are identified as the unforeseen rapid progress of each labour,'' the review said.
"An additional contributory factor pertaining to one woman was the lack of essential equipment available in the Lumsden Hub in the presence of specific risk factors which could constitute the need for full resuscitation capacity.''
Mr Fleming said the SDHB was now reviewing its midwifery leadership roles to improve its systems, and had agreed formal back-up arrangements for midwives in remote locations.
* For more, see tomorrow's Otago Daily Times