The maternal mortality rate is three times higher for Maori than New Zealand Europeans, and behind each death is a considerable burden of 'near misses' or severe acute maternal morbidity (SAMM). The effects of the death or severe harm of a young mother on her whanau, health workers and society as a whole cannot be underestimated. This research focuses on severe maternal infection (sepsis), which is an increasing cause of death worldwide. It involves a descriptive audit of 20 cases of maternal sepsis, looking in depth at a range of data with the goal of identifying preventable factors and developing a series of recommendations to be reviewed by a multi-disciplinary committee. These recommendations have the potential to be developed into clinical interventions which will act to reduce the burden of harm of severe maternal morbidity and will directly contribute to improving health outcomes for Maori wahine.