Deputy Health and Disability Commissioner Rose Wall has criticised Waikato District Health Board for what she calls "cumulative deficiencies" in challenging circumstances.
The woman - referred to as A - who was in her 30s at the time, first went to the emergency department when she was 12 weeks pregnant with headaches and nausea.
She was found to have high blood pressure, but the investigation found there was "no effective plan" in place to monitor her in the community on an ongoing basis.
She was admitted to hospital weeks later, after it was found the babies were failing to grow properly and one had an abnormal heart rate.
In her complaint, the mother said she repeatedly raised her fears for the wellbeing of her babies, but doctors did not act on her concerns.
At 30 weeks and three days gestation, it was found one of the twins had died.
In her complaint to the Health and Disability Commission, the woman said after being told her daughter was dead, staff ignored her cultural need as Māori to have family present at the birth.
"I needed for one that they knew they were safe [and] two that if not graced by me or [their] father, at least be graced by someone I trust with my life, they never gave me a chance ... they tried to snatch my phone from me before I was able to contact anyone."
Hospital staff told the investigation team that after confirming there was only one foetal heartbeat, the consultant and registrar informed the mother one baby had died.
"Ms A was distressed and wanted to go outside for a cigarette. She was advised against this because of the risk to herself and the live twin. However, a midwife assisted Ms A to go outside, at which time Ms A had an antepartum haemorrhage with suspected placental abruption.
"The midwife took her back to the delivery suite immediately and activated the emergency alarm."
Both babies were delivered by emergency caesarean section.
Staff spent 16 minutes attempting to resuscitate one twin but there were no signs of life.
The boy was born healthy and transferred to the Neonatal Intensive Care Unit.
Te Whatu Ora told the Commission that the reason why the babies were not delivered earlier was not related to staff shortages but on "clinical indications".
In response to A's cultural concerns, Te Whatu Ora said the medical and midwifery team caring for A were all genuinely concerned and tried their best to provide support through her grief, and they encouraged whānau to be with her at all times.
Staff supported the whānau's request for karakia while A was in the Intensive Care Unit and arranged for her dead daughter to be beside her in a cooling cot.
"Te Whatu Ora said that staff tried to accommodate Ms A and her whānau's requests wherever possible, and that as soon as it was safe for Ms A to do so, she was transferred to a room where whānau had free access to grieving patients 24 hours of the day."
They also facilitated a whānau hui, at which they worked with A and her whānau to ensure they were accommodated to pay their respects to the baby.
Wall accepted the circumstances were challenging, "but the cumulative deficiencies in the care provided amounted to the breach".
She was critical of Waikato DHB's care following the first ED review when an effective plan was not put in place to closely monitor the woman's condition in the community.
Obstetrician Sornalatha Vasan, who provided expert advice to the Commission, said she should have been more closely monitored once she was admitted, although this was challenging.
"To continue conservative management [there] needed [to be] close monitoring with adequate CTG monitoring regularly which was difficult with [Ms A] since she was out of her room most of the time … heav[ily] smoking and [an] inability to get good CTG (cardiotocography/heart monitor) readings."
Wall was also critical that midwives failed to escalate matters or seek medical opinion when they could not find two separate heartbeats at an earlier point.
She recommended Te Whatu Ora Waikato provide a written apology, train staff on the management and monitoring of hypertension and pre-eclampsia in twin pregnancies, and provide HDC with a copy of its cultural/kaupapa training framework outlining how the practice of tikanga with patients and their whānau is developed with all hospital staff.
