The death of a newborn baby who was released just hours after being born at Wellington Hospital has been blamed on a missing lab test.
The health and disability commissioner, Ron Paterson, has issued a ruling on the death, but is not publicly releasing his report.
The girl died in November 2007 at a time when the Capital and Coast District Health Board was under scrutiny for encouraging mothers to leave Wellington Hospital quickly after giving birth.
She and her mother were discharged five hours after the birth, which had been preceded by 30 hours' labour, and the woman later complained that she had felt pressured to leave.
But Mr Paterson says that that did not contribute to the baby's death.
While he has no doubt the mother felt pressure to leave, he says that the death was due to a misplaced diagnostic swab, which meant that a group B streptococcus infection went undetected.
The hospital's clinical director of women's health, John Tait, says that since the baby's death significant steps have been taken to improve the hospital's systems. The hospital says it wants to meet the baby's family to apologise for what it describes as a tragic event.