Health NZ Review Finds Rotorua Hospital Missed Placenta Condition

Sage Lewis died from severe blood loss at Rotorua Hospital on November 16, 2019, after a rare placental condition was missed on successive occasions during antenatal scans and hospital admissions. A Health New Zealand learning review confirmed the fatal anomaly went unrecognised across multiple clinical providers before the infant’s emergency delivery at 38 weeks.

In Plain English: Understanding the Clinical Takeaway

• Vasa Praevia: A rare pregnancy complication where fetal blood vessels run unprotected through the membranes near the cervix, making them highly vulnerable to rupture when labor begins.
• Velamentous Cord Insertion: An abnormal umbilical cord attachment where the vessels insert into the membranes instead of the placental mass, lacking the protective tissue surrounding the vessels.
• Succenturiate Lobe: An extra, smaller section of the placenta connected to the main disc by blood vessels, which frequently creates the anatomical setup for vasa praevia.

The Anatomy of an Undetected Placental Emergency

Sage’s mother, Hannah Nicholson, underwent routine monitoring throughout her pregnancy, including an ultrasound at 20 weeks and two days’ gestation at Rotorua Hospital. That scan identified a succenturiate lobe with blood vessels running close to the internal cervical opening. The review revealed the finding was not recognized.

Subsequent scans and hospital admissions failed to correct the oversight. At 30 weeks, scans indicated the condition remained present, yet the radiology report omitted an explicit mention of vasa praevia. When Nicholson was admitted the following day for high blood pressure, medical staff noted the 30-week scan without recognizing the risk, discharging her without further action. Subsequent visits at 32 and 33 weeks similarly resulted in missed diagnoses, with one report erroneously claiming the condition had resolved.

Labor Induction and the Fatal Hemorrhage

On November 14, 2019, Nicholson’s labor was induced at 38 weeks and one day following the spontaneous rupture of membranes. Labor progressed normally until a sudden drop in Sage’s heart rate was recorded at 7:28 p.m. Medical staff performed an emergency caesarean section, delivering the infant at 8:33 p.m. in poor condition.

A senior medical officer identified a uterine clot and assessed there had been a placental abruption. Post-mortem examinations later revealed that the umbilical cord featured a velamentous insertion. One of the unprotected blood vessels traversing the membranes—the umbilical vein—had torn during labor, causing rapid and severe fetal blood loss.

Timeline of Antenatal Scans and Clinical Omissions at Rotorua Hospital

Gestation Age	Clinical Event	Imaging Findings	Clinical Outcome
20 Weeks, 2 Days	Hospital Ultrasound	Succenturiate lobe with vessels near cervix	Vasa praevia present but unrecognized
25 Weeks	Hospital Admission	Antepartum haemorrhage; succenturiate placenta noted	Condition missed
30 Weeks	Outpatient Scan	Vasa praevia present	Not explicitly stated in report; missed during admission
33 Weeks	Ultrasound Scan	Erroneous report	Condition incorrectly documented as resolved

Systemic Transparency and Acknowledgement

Health New Zealand (HNZ) Lakes conducted a learning review examining clinical care, communication, staffing, and environmental factors contributing to the outcome. While failures in the duty of care spanned multiple providers, Nicholson emphasized the value of institutional accountability.

“Being open about what went wrong has helped drive important systemic changes, which will hopefully prevent other whānau from experiencing such a tragic loss,” Nicholson told NZME.

Pathways Forward for Antenatal Safety

• Health New Zealand Lakes. Learning Review.