The Waikato Coroner says the failure of an inexperienced midwife and of hospital staff to recognise a problem labour contributed to the death of a newborn baby at Waikato Hospital.
Adam Barlow died shortly after being born in an emergency caesarean in October 2009 after his mother went through an horrific labour that led to her having three cardiac arrests, a partial stroke and a hysterectomy. The baby died from lack of oxygen to the brain.
The Coroner's findings says a failure of midwife Jenny Rowan to recognise that the progress of the labour was not normal and her failure to convey the urgency of the situation to Waikato Hospital when the mother was transferred contributed to the death.
Coroner Gordon Matenga says the failure of the hospital staff to recognise the urgency of Mrs Barlow's situation and speed up the delivery also contributed to the baby's death.
Mr Matenga has recommended that the guidelines for referring patients be amended, junior doctors consult a specialist when a woman with a complicated birth is admitted and that midwifery training be reviewed.
The baby's father Robert Barlow says he hopes the Coroner's recommendations will be acted upon.
"We're not angry with the midwife, I'd say we're disappointed," Mr Barlow told Morning Report.
"We've forgiven her for what happened that day but we don't think that should mean that you shouldn't be responsible for your actions."
Mr Barlow wants all junior midwives to be supervised before being allowed to go out into independent practice.
"We're always told by the professional bodies that a midwife is a midwife, whether they've been qualified for 10 years or whether they've been qualified for six months, they're all competent.
"I just think that's totally crazy. Experience is everything."
Midwife disputes ruling
The lawyer for midwife Jenny Rowan issued a statement on Wednesday saying she again expresses her sincere condolences to the Barlow family.
The statement says Ms Rowan regrets any part that she may have played in this tragic outcome but does not accept her training and degree of experience contributed to it.
"With the greatest of respect, my view of the evidence as stated in my submissions differs to that of the Coroner."
Ms Rowan has undergone further training and is still practising though at present is on maternity leave.
Waikato District Health Board says it has implemented changes including better supervision of junior staff and better referral procedures on emergency care.
The College of Midwives says major education and practice changes have been introduced over the past few years.
The College says it has concerns over some aspects of the hospital emergency response, saying it was a failure of the hospital to meet its responsibilities to the midwife and consequently to the mother and baby.
In a statement, it said Ms Barlow should have been admitted to hospital by a specialist who would have defined the level of care needed, but the opportunity was lost when she was admitted by a junior registrar.