A senior doctor ignored warnings from midwives and another doctor and delayed carrying out an emergency caesarean, with tragic results.
The Health and Disability Commissioner says the unnamed obstetrician made a serious mistake in 2011 that ended with a stillborn baby.
A 46-year-old woman having her fourth child developed serious complications and a heart monitor showed that the baby was in serious trouble.
However, the obstetrician delayed ordering an emergency caesarian, despite mounting concern of two midwives and the doctor. Instead, he asked for a fetal blood sample before carrying out the caesarian, but the baby was stillborn.
Health and Disability Commissioner Anthony Hill said on Monday the senior doctor should have listened to the concerns of staff present. He said the others did what they could, but couldn't change his mind.
"This is a very difficult and high stakes environment, and so we need teams to be working well together. A critical feature of this case was first the clinical error that was made and, secondly, failure to hear clear warnings from colleagues 'We need to act now.'"
A medical expert said the slowing fetal heart rate should have alerted the doctor to the fact that it was a matter of life or death.
Mr Hill also faulted the senior doctor's unprofessional manner and referred him for possible legal action. He would not say where the case occurred.
