You are not permitted to download, save or email this image. Visit image gallery to purchase the image.
Mother-of-two Rozzana Paitai was taken to Middlemore Hospital by her father in the early hours of October 21, 2011, after developing a sore right arm.
The 21-year-old died two days later after suffering a stroke from a blood clot in her brain, a condition associated with pregnancy.
She had given birth to her second son, Jonah, three weeks earlier.
Her father, Tara Paitai, said he decided to speak out about his family's experience after reading in the Herald about how young, vulnerable Pacific and Maori women felt mistreated when giving birth at Middlemore Hospital.
"I just didn't want it to happen to anyone else," he said.
"My last words to her were 'I'll be back later to pick you up' and I told her I loved her and all that stuff," Mr Paitai said.
The Counties Manukau District Health Board (DHB), which contacted Mr Paitai after APNZ requested comment on his daughter's case, said it was unaware Mr Paitai had felt "unresolved" about her death but had offered to meet him to discuss her case, a spokeswoman said.
Mr Paitai said while a hospital representative had told him they had asked his ex-wife whether she wanted to talk about his daughter's case, he had never been approached.
"She would have just shut down, so I never knew about it."
Mr Paitai, who said he planned to take the DHB up on the offer, described how traumatic the experience had been for his family.
"When I spoke to the doctors, they said 'yeah, she'll be all right, come back in the afternoon and you can take her home'."
Later that day, he returned to find his daughter "had tubes in her".
"The doctors were going 'oh yeah, she might not live'. It was quite heartbreaking really," he said.
Adding to the family's distress was news Ms Paitai had been given an extra dose of the blood thinning medication heparin due to a staff error.
While a coroner's inquest found the error, caused after a nurse misread Ms Paitai's test results, did not directly caused her death, Mr Paitai said the way staff behaved had been unacceptable.
"I told [Rozzana] that they would look after her and we could go home afterwards.
"If I had more information I would have just stayed there, wouldn't have cared about work."
The family also felt blindsided by the investigation into Ms Paitai's death.
"They came back to say we need to get all the reports because the coroner was taking over the case. We got interviewed by the police, 11 o'clock on that Sunday night," he said.
No one explained why the police and the coroner had become involved before the interviews, Mr Paitai said.
Ms Paitai's body was also kept from her family for several days for the investigation.
"They took her away that Sunday night. We didn't get her back until Wednesday. I had family fly in and they were asking where she was and I wasn't allowed to say anything."
DHB chief medical officer Dr Gloria Johnson said a substantial review into the medication error had been undertaken, and processes had been implemented "to reduce the potential of this ever happening again".
"At the time, we understood that we had disclosed this error to the family and we are sorry that they did not feel adequately informed or supported by our staff," she said.
Rozzana Paitai: Coroner Katharine Greig findings
* Died after suffering a stroke and swelling in her brain due to a blood clot
* Uncommon condition which is most often associated with pregnancy
* Had given birth to her second child three weeks earlier
* The extra dose of heparin incorrectly administered to her two days before she died did not cause her death
* Drug error, due to a nurse misreading the time of Ms Paitai's blood test results, could have had "potentially fatal consequences"
* Hospital staff response to the error was slow
* Death was not an avoidable one
* Middlemore Hospital has reviewed processes for error recovery which may have resulted in the slow response to the extra heparin dose
* A new blood test result template has been introduced showing the date and time in several places
- By Teuila Fuatai of APNZ