A woman in her 30s needed an emergency caesarian and gave birth to a stillborn infant after poor care for her Type 1 diabetes, a report has found.

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The report from Health and Disability Commissioner Anthony Hill found the MidCentral District Health Board in Palmerston North failed to provide the standard of care required for the woman in 2014.

He said the woman - named in the report as Mrs A - had a history of poorly controlled Type 1 diabetes and was pregnant for the third time.

She had been diabetic since she was a child and was under the care of the DHB's joint multidisciplinary diabetes and pregnancy service.

Mr Hill added that diabetic ketoacidosis (DKA) in pregnancy could compromise both the fetus and the mother, and usually occurred in the later stages of pregnancy. Nausea, vomiting, thirst, excessive urine, thirst, abdominal pain and occasionally changed mental status were symptoms.

He said Mrs A's control of her blood-sugar levels during an earlier pregnancy was poor, but her blood glucose levels were generally stable in the third pregnancy, until 29 weeks' gestation.

During the seventh month of the pregnancy, however, Mrs A went to a hospital emergency department with a headache, nausea and general illness. She was not assessed at the ED but sent directly to the delivery suite.

A midwife there recorded raised levels of glucose and ketones, which are produced by untreated diabetes, but fetal movements were good and there were no overriding concerns.

She was given fluids for dehydration because of vomiting, and pain relief for a tension headache, but was not seen by a medical consultant or senior doctor. She was discharged the next day and Mr Hill said there was no evidence the joint multidisciplinary service was notified about the admission, or any involvement in Mrs A's management while in hospital.

But she was ill on the way home and arrived back at the hospital emergency department shortly before 3am next morning by ambulance. She was short of breath, needed to urinate whenever she drank and there were reduced baby movements.

Soon after, no fetal heart beat could be detected, DKA was suspected and, while the baby was now known to be dead, an emergency caesarian was needed, because of the way the baby was lying and to protect Mrs A from fever and infection.

Mr Hill said that on examination of Mrs A, an obstetrician "realised she was in a dire, life-threatening condition" with a severe, persistent fast heart rate, which was getting worse, and that her level of consciousness was deteriorating.

The stillborn child was delivered and Mrs A was discharged from intensive care to the maternity unit and went home three days later.

But Mr Hill said the discharge summary "contained no advice to Mrs A, her GP or her LMC [lead maternity carer] about the reasons why Mrs A developed DKA, or information on how to reduce the risk of recurrence".

Monitoring of Mrs A's blood glucose levels was an issue. An investigation carried out afterwards by the DHB said there was no national or international consensus on the frequency of blood glucose or HbA1c monitoring in New Zealand, but in Britain the National Institute for Healthcare and Excellence suggested thrice-monthly.

Mr Hill said the signs and symptoms that Mrs A might have expected to experience, should she be suffering from DKA, were not communicated to her adequately and her diabetes was not monitored sufficiently. There was also "little proactive action by the Diabetes Service to check whether there have been admissions that require its support".

An endocrinologist told him the multidisciplinary service was "limited by lack of staff" and that clinics were significantly overloaded. She added the service had been "compelled to ration care" and that she had raised concerns with the DHB many times since 2013.

Mr Hill said it amounted to a "cumulative picture of poor care".

He recommended: a review of the staffing of the joint multidisciplinary service; that the DHB consult with other DHBs over consistent glycaemic targets for pregnant women; that all disciplines are informed and involved in treatment decisions; and that the training given to junior doctors on the assessment of patients be reviewed.