A midwife and a doctor have been censured for not picking up problems which led to the death of a newborn baby girl at a New Zealand hospital.
The Health and Disability Commissioner today released a report into the death of the baby two days after she was born in 2008.
It found a doctor, known as Dr E, had made mistakes in diagnosing and monitoring signs of fetal distress leading up to the birth.
A midwife, known as Ms D, was also censured for failing to take her concerns about the baby's health above Dr E's head to an on-call consultant.
Both medical professionals blamed extreme fatigue and exhaustion for some of their mistakes leading up to the baby's death.
The report shows the baby's mother went into labour in late 2008.
She had been told to give birth at a hospital because of risks associated with her baby's large size.
A series of medical problems went unrecognised throughout her labour, including 90 minutes of abnormal scans of the baby's heart rate.
After a long labour, the baby's head was delivered but her shoulders were obstructed.
She was eventually delivered floppy and not breathing and only took her first breath after 24 minutes of intensive resuscitation.
The baby died two days later in the neonatal unit of a large public hospital.
In HDC interviews after the death, the midwife known as Ms D admitted she had "concerns all along" over the birth.
However, she was reluctant to call an obstetrician to discuss her concerns.
She was exhausted after being involved in four births that day and opted to rely on Dr E to refer problems with the baby's health to a specialist.
"Convention has it that as a midwife you abide by the registrar's decisions, and the only person to directly contact the consultant on call with issues re a current patient is the registrar.
"I spent the latter part of the shift feeling disempowered and fearful of the outcome of the delivery."
Dr E was censured for not following up on whether the baby's mother had been effectively treated for dehydration and for not reviewing heart rate readings.
The HDC report said he had breached the family's right to receiving professional and skilled care.
"While I note Dr E's submission that excessive fatigue contributed to the errors he made, in my opinion, Dr E must still take responsibility for those errors....
"I note that Dr E has gained significant learning from this tragic case."