Palmerston North's MidCentral District Health Board and four of its midwives have been faulted over the care given to a baby who suffered severe brain damage soon after birth.
Health and Disability Commissioner Ron Paterson says the midwives failed to keep the records which were needed and which may have prevented the baby's deterioration.
Mr Paterson says the baby appeared healthy when he was born at Palmerston North Hospital in July 2003.
The mother and baby were transferred to a maternity unit where the baby became jaundiced, sleepy and disinterested, and reluctant to feed.
Mr Paterson says two-and-a-half days after birth, the baby suffered from low blood glucose. The boy suffered brain damage and became significantly disabled.
Mr Paterson says the midwives failed to document key things such as the length and quality of feeding and the DHB should have had systems to prevent this, but has improved services since.
MidCentral DHB says it has done all it can to ensure there is no repeat of the inadequacies in care.