A midwife will have her competency reviewed and will have to undergo further training because of a baby's death.
The Health and Disability Commissioner has reviewed the 2014 case, in which a 32-year-old woman's baby was stillborn.
Anthony Hill found the woman's husband phoned the midwife several times saying his wife was suffering strong abdominal pain.
After the third call, the midwife visited the woman and began an examination but the woman then decided she did not want it to proceed.
Mr Hill said the woman was not told the full reasons for the examination and therefore did not make a fully informed choice.
A fourth call five hours later led to advice that she did not need to go to hospital yet, but an hour later the midwife was told the couple were going to hospital anyway.
The baby was born dead to due to the inflammation of fetal membranes from bacterial infection.