Health and Disability Commissioner Anthony Hill has criticised a midwife's failure to take proper care of a pregnant woman.
Mr Hill says a week before the woman's due date, she sent a text to the midwife to say she was scared about her baby's lack of movement, and the midwife responded via text.
On the way to hospital to give birth the 24-year-old woman, who was in advanced labour, fell off the car's back seat when her mother got lost and drove through a barrier.
She gave birth minutes after arriving, but the baby had no heartbeat and couldn't be brought to life.
Mr Hill says the midwife, who has not been named, breached several aspects of the Code of Health and Disability Services Consumers' Rights.
He says she should have followed up her text with a phone call to the woman.
The midwife has been referred to the Midwifery Council for possible disciplinary action.