The former Waikato DHB's under fire -- after a woman lost a twin during pregnancy

The woman first went to ED in 2019, when she was 12-weeks pregnant, complaining of headaches and nausea.

The Deputy Health and Disability Commissioner says no monitoring plan was put in place.

Later in the pregnancy, she was admitted to hospital and told one twin had an abnormal heart rate -- and both were delivered by caesarian.

After one baby died the woman's whanau was not notified, and nor was a cultural support person called.