A baby who died during a home birth was not property monitored during labour and there was no oxygen on hand to resuscitate her, an inquiry has found.
Health and Disability Commissioner Anthony Hill has criticised three midwives involved and recommended that the lead midwife have further training.
The girl died from lack of oxygen after she was born with the umbilical cord around her neck.
In a report released on Monday, the commissioner said the lead midwife did not monitor the baby's heart rate, which could have alerted her that something was wrong.
Mr Hill found that the mother refused surgical intervention that could have helped because the lead midwife didn't pass on enough information, including anaesthetic being available.
The midwife did not have oxygen with her to help resuscitate the baby and a back-up midwife forgot to bring her equipment, he said.
The third midwife was criticised for not keeping proper records.