The coroner has criticised a midwife and a trainee specialist for poor communication and missing important warning signs leading up to the death of a baby.
The baby boy was resuscitated after an emergency caesarean at Hawke's Bay Regional Hospital in June last year, but died 12 hours later.
The coroner says the midwife, who cannot be named, made several bad judgement calls including relying on text messages from the mother to make clinical assessments.
Once she became aware the woman was bleeding abnormally and had high blood pressure, she took too long to send her to hospital.
There were further delays at the hospital while the doctor finished her lunch and then failed to recognise the baby's abnormal heartbeat.
The coroner says the tragedy shows the importance of having a clear understanding about who has clinical responsibility for the mother at all times.
Medical Association spokesperson, Hawke's Bay GP Mark Peterson, says several errors contributed to the baby's death, but the key one was poor communication.
Dr Peterson says there has been a lot of work by doctors' and midwives' organisations to strengthen communication and guidelines on working together.
A group pushing for an overhaul of maternity services says the errors that led to the death of the Hawke's Bay baby are too common.
Action to Improve Maternity spokesperson Jenn Hooper says the fact that about 700 babies a year die in New Zealand around the time of birth should be ringing alarm bells.
She says official figures show at least a fifth of those deaths are preventable, and her research suggests it could be as many as a third.