Health and Disability Commissioner Ron Patterson has been highly critical of a former Southland obstetrician and gynaecologist who helped deliver a baby girl who later died.
The doctor, who had recently moved to New Zealand from the United States, resigned from Southland District Health Board soon after the delivery.
The baby died in 2006, a day after her birth, because of bleeding between her skull and scalp, and blood loss from a torn umbilical cord.
Mr Patterson says the specialist concerned, referred to only as Dr B, failed to provide the baby's mother with adequate information about delivery options, and did not obtain informed consent for a third attempt at a vacuum-assisted delivery.
He pressured other health workers into making false entries in clinical notes and made misleading entries himself.
Mr Patterson will decide whether to begin disciplinary proceedings against Dr B.