1. The cause of death of the twins was extreme prematurity. The foetuses were not viable in terms of gestational age.
2. (a) and (b) (i) The actual number of doctors at the Tambo Memorial Maternity Complex:
(ii) The actual number of nurses at the Tambo Memorial Maternity Complex:
(iii) Other Clinical Support at Tambo Memorial Complex
3. (a) to (c) The patient delivered vaginally spontaneously and the twins died immediately after birth due to extreme prematurity.
4. No health professionals were found to have acted wrongly.
5. Tramadol is safe in pregnancy.
END.