- This is incredibly sad for those affected, says Sergio Padoan chief medical officer at CSK.

Only one of the woman's conversations is documented and it says that the woman described nausea, headache, pressure in the stomach, discharge of water, contractions, mucus and at some point some blood.

The message: Stay at home

The message she received was that she would stay home. The day before the birth, the woman did not feel any fetal movements and was referred directly to the delivery department where fetal death was noted.

- The symptoms the woman had are not immediately linked to a baby dying in her stomach. The question here is whether we could have acted differently to avoid this injury. We will also review our routines on how we document calls to avoid errors at that point, says Chief Physician Sergio Padoan.