A newborn baby died at a Northland hospital after a midwife failed to use appropriate equipment and was "embarrassed" to ask for help, the Health and Disability Commissioner has found.
Commissioner Anthony Hill launched an inquiry into the death of the baby in 2010, after the child's mother complained. The baby died in late 2009, about 13 hours after birth.
He found when the woman's labour was induced at the hospital, a cardiotocogram (CTG) to monitor the foetal heart rate actually recorded the maternal heart rate, so an abnormal foetal heart rate was not detected for several hours.
Details identifying the mother and child, the hospital midwife (Ms B) and two NDHB staff members also involved - lead maternity carer (LMC) Ms C and clinical nurse manager Ms D - have not been released.
Mr Hill, found that Ms B failed to use appropriate equipment, failed to correctly read the CTG or request assistance.
"She said that, although she was uncertain, she was embarrassed to ask for help," the commissioner found.
He said that if the midwife remained uncertain, she had a professional obligation to act on her concerns.
The woman's LMC and a senior hospital midwife also failed to appropriately monitor the maternal and foetal wellbeing. The LMC left the hospital without adequately arranging for an epidural or handing over the woman's care to hospital staff.
The clinical midwife manager provided inadequate supervision to the hospital midwife.
The commissioner said the DHB's system, designed to ensure that patients receive timely, appropriate, specialised care, failed to deliver. Several providers and the DHB's systems let the woman down and breached the Code of Health and Disability Services Consumers' Rights (the Code).
The HDC made a number of recommendations that have been complied with.
Ms B, Ms C and Ms D all wrote letters of apology to Ms A for their breaches of the Code.
NDHB carried out an internal review after the incident and made significant changes to its systems, including training on the use of CTGs, and added supervision and education for new midwives.
Mike Roberts, NDHB chief medical officer, said guidelines had been put in place to ensure that care is delivered in a consistently safe manner.
"We have increased staffing levels significantly and have recently been recognised as leading the way with the implementation of the new National Maternity Quality and Safety Standards," Dr Roberts said.