An unnamed senior doctor and the Waikato District Health Board have been faulted over the death of a baby soon after her birth.
The case has been highlighted in findings released on Monday by Health and Disability Commissioner Anthony Hill.
The case concerns a 21-year-old who was pregnant for the first time in late 2008 and whose baby was not growing correctly.
Mr Hill says the mother attended five appointments at a clinic in the Women's Outpatient Department of Waikato Hospital, but routine antenatal blood pressure and other assessments were not done at two appointments.
After her fifth appointment, the mother became seriously unwell with toxaemia and gave birth by emergency caesarian, but her daughter died within days.
Mr Hill says the obstetrician should have been more vigilant and ensured that all tests were done and the DHB should have ensured its systems were adequate.
Pip Wright, the DHB's associate midwifery manager, says the clinic is the only one serving much of the central North Island and was inundated at the time, but improvements have been made.
"We just didn't plan for the increase in volumes and therefore we were put on the back foot when this did happen to this poor lady. It showed that we just had too many people accessing that clinic."
Ms Wright says access is now better controlled and the clinic has more space than it did three years ago, as well as its own midwife.