Two midwives have been told to apologise to the parents of a newborn baby that lost a large amount of weight and died soon after birth.
The Health and Disability Commissioner said excessive weight loss started in hospital and continued once he was sent home.
The baby deteriorated and eventually needed intensive care for severe dehydration, before dying in 2014.
Anthony Hill said the baby was born weighing 4.5 kilograms but was otherwise well when discharged with his first-time mother.
The lead midwife noticed the baby's weight had dropped by almost 17 percent in the first five days of life, but failed to follow Health Ministry guidelines and tell the mother to take her baby to a paediatrician.
Ministry guidelines require midwives to refer babies who have lost more than 10 percent of their weight since birth to a child health expert.
Mr Hill said the midwife thought this unnecessary, and had another plan.
"It wasn't for the midwife to make an assumption about what the paediatrician would have formed a view on, so it's an important check in the process that did not occur and then of course that made the plan that was being put in place to assist the baby even more important."
Mr Hill said the mother was unsure and had relied on the midwives.
He has recommended the Midwifery Council reinforce to all midwives the importance of following referral guidelines.