Three midwives and Northland District Health Board have been criticised over a birth in 2009 that ended in the death of a newborn baby.
The case is detailed in a report issued by Health and Disability Commissioner Anthony Hill.
The case involved a pregnancy that was normal until the woman, 21, went into hospital in 2009 to be induced.
The birth became an emergency and the baby had acute brain damage due to asphyxia, dying 13 hours after the birth.
Mr Hill says there were failures by all three unnamed midwives involved, including the hospital midwife who did not know how to use the CTG machine and was incorrectly monitoring the mother's rather than the baby's heart rate.
The clinical midwife manager failed to show the less experienced midwife what she needed to do. Mr Hill also found a pattern of deficiencies in the DHB's services.
Mr Hill is calling on all health professionals to speak out if they are in doubt or need help.
"We've got a professional in a situation lacking confidence but feeling embarrassed to get help. Now while that person had an obligation to speak up for her own professional obligation we also need an environment where it's easy to speak up, where it's expected to speak up and to reach out and to talk."
The DHB says services have since improved.