Chapter 1: Learning from death
In February 2011, in a New Zealand (NZ) coronial inquiry that attracted widespread media attention, Robert Barlow, father of the deceased bay, Adam, explained. We don't want our son to be remembered as the baby who died at the hands of a flawed maternity system. We want him to be remembered as the baby who brought about positive change in the maternity sector for the good of future mothers and babies. Coroner Matenga found that baby Adam died after a "series of failures" by the midwife contributed to a hypoxic intrauterine environment during a prolonged stage of labour due to foetal malposition.