A community-based midwife has been told to apologise and may face further action over a birth where the baby was stillborn.
The case is documented in a report today by Health and Disability Commissioner Anthony Hill.
The 27-year-old first-time mother booked with a registered midwife as her lead maternity carer (LMC) in 2014.
The woman had a body mass index (BMI) of 44.6 and the midwife should have recommended she see a specialist, as required for any mother with a BMI over 40.
That did not occur. Instead, the woman went into labour spontaneously at term, staying at home until her membranes ruptured at 7am one day.
At hospital, the LMC midwife managed the birth. Mr Hill said, although the foetal heart rate was non-reassuring, she opted to discontinue cardiotocography monitoring. Later, when this midwife could not hear the foetal heart rate, she called for assistance.
The baby boy was stillborn later that day and a post mortem found he died as a result of infection with Group B streptococcus.
Mr Hill was highly critical of the care provided by the LMC midwife. Despite the presence of clear risk factors, she did not recommend the woman's care be transferred to a specialist earlier in her pregnancy, he said.
She also failed to document key discussions with the woman, and did not follow recommendations that continuous foetal heart rate monitoring take place in labour where a woman has a high BMI.
Mr Hill said in his report that the midwife was no longer practising. But, he said, should she wish to return, the Midwifery Council would decline to issue a practising certificate before undertaking a review of her competence - and he supported that.
He has referred the case to the independent director of proceedings for possible further action.
He has also asked the midwife to apologise.
The complaint that led to his investigation came from an obstetrician and gynaecologist and was backed by the family.