A midwife failed to provide appropriate care to a young woman during her pregnancy and birth, after her baby girl died shortly after birth.
A report by the Health and Disability Commissioner said the young woman, who was pregnant with her first child and wished to have a home birth, had chosen the services of a registered community midwife as her lead maternity carer. She also had a back-up midwife.
On the day the young woman went into labour, her midwife arrived at her home with a second back-up midwife.
The baby was later born with her umbilical cord wrapped around her neck several times. The midwife did not have an oxygen cylinder and the second back-up midwife had forgotten her home birth equipment.
Attempts to resuscitate the baby showed little improvement, and an ambulance was called where the baby was given advanced resuscitation, and then transferred by helicopter to the neonatal intensive care unit.
After being assessed at the neonatal intensive care unit a decision was made to withdraw ventilation and the baby died.
The commissioner's report said the midwife failed to monitor the woman during labour with reasonable care and skill, and stated it was her responsibility to provide all home birth equipment including oxygen.
It stated her actions following the birth were concerning and unprofessional.
The young woman's back up midwife was also found to have failed to complete antenatal growth chart accurately.
The commissioner found the midwife to have breached the Code of Health and Disability Services Consumers' Rights for her failures, and unfavourable comment was also made about the two back-up midwives.
As a result all three midwives were asked to provide written apologies to the woman.
The commissioner also emphasised the importance of midwives behaving in a manner that is objective and professional, while also being caring and compassionate.
He has recommended the lead midwife undertake further training on informed consent, record-keeping, and professional boundaries.
He has also recommended she undergo a Special Midwifery Standards Review through the New Zealand College of Midwives.