The Health and Disability Commissioner has found two midwives did not take appropriate action during a birth when a baby was born with no audible heartbeat.
In late 2010 the pregnant woman was admitted to hospital and the baby's fetal heart rate was found to be normal. Almost three hours later it had dropped significantly, and the midwife carried out more tests before calling the assistant charge midwife for help.
The assistant charge midwife spent nine minutes trying to find a heartbeat but couldn't, and called for the obstetric registrar, who delivered the baby and found it had no audible heartbeat.
Immediate resuscitation was unsuccessful.
The commissioner concluded the first midwife did not seek help quickly enough, had poor communication with the pregnant woman and provided unacceptable documentation.
The assistant charge midwife was found to have not requested assistance promptly.