Poor communication and lack of supervision are among the failures identified in the lead-up to a delivery of a baby girl, who died shortly after she was born.
The baby, who was 10 days overdue, was born in a public hospital in the Capital and Coast District Health Board (DHB) region with the umbilical cord wrapped around her neck and shoulder; she died the following day.
The report into the 2012 incident, released this afternoon by Health and Disability Commissioner Anthony Hill, found the Capital and Coast DHB and an obstetric consultant in breach of the Code of Health and Disability Services Consumers' Rights.
The report says a registrar, who had worked at the hospital for only two weeks, proceeded unsupervised with a forceps trial and subsequent Caesarean section, despite the on-call consultant intending to carry out the procedures himself.
The report says the consultant failed to communicate clearly and, while the registrar should have known she was out of her depth, she had not received a complete induction.