A new born baby who had lost an "excessive" amount of weight died after a senior midwife failed to check on the boy in person.
The baby had dropped 16.7 per cent of his birth weight after he and his mother were discharged from hospital. A feeding plan was put in place, but a senior midwife tasked with checking on the boy and re-weighing him did not visit the boy and his mother at home.
He was later admitted to a neonatal intensive care unit with severe dehydration, hypernatremia, and intracranial haemorrhage. He died shortly afterwards.
Two midwives breached the health code by failing to provide adequate care to the new born, the Health and Disability Commissioner Anthony Hill said in findings released today.
The baby boy was born healthy and "in good condition", the report said, but then experienced unstable blood sugar levels in the immediate post-natal period.
His levels stabilised and he was discharged under the care of his mother's midwife.
However, on the third day at home, the midwife weighed the boy and discovered he had suffered a 16.7 per cent drop in weight since birth - or 770g.
The midwife noted that the weight loss was "excessive", but after assessing the boy did not identify any other issues of concern.
A plan was put in place for regular feeding and to re-weigh the baby in three to four days' time.
However, the boy was not re-weighed in accordance with the midwife's plan, despite her requesting the senior midwife to do so when she was on leave, Mr Hill said.
Instead, the senior midwife telephoned his mother and, after talking to her, was reassured the baby was well and instead arranged for a third midwife to visit the woman later in the week.
But the boy's mother contacted the backup midwife before that consultation took place worried that her baby was lethargic and difficult to feed.
It was then that he was admitted to hospital, where he was assessed by the on-call paediatrician as weighing 3.5kg - a 22 per cent weight loss since birth - and died shortly afterwards.
In his report, Mr Hill said that in the circumstances of a baby losing more than 10 per cent of his or her birthweight, the Ministry of Health Guidelines for Consultation with Obstetric and Related Medical Services [the Referral Guidelines] require LMCs [lead maternity carer] to recommend consultation with a specialist.
Mr Hill was critical of the midwife's decision not to follow the Referral Guidelines in this case and the plan that the midwife put in place to manage and recheck the baby.
"The Referral Guidelines are meaningless if they are not consistently, and appropriately, applied", said Mr Hill, finding the midwife had breached the code.
The senior midwife was also found to have breached the code for failing to assess the baby in person and re-weigh him, relying instead on the information provided by the baby's mother over the telephone, and by failing to provide timely handover to the back-up midwife.
Mr Hill was critical of the back-up midwife for failing to follow up with the woman in a timely manner, and he was also critical of the District Health Board's failure to ensure that staff were aware of the recommended management for a new born with unstable blood sugar levels.
The midwives apologised to the woman, and the senior midwife undertook further training in relation to the care of new borns, the report said.
Mr Hill also recommended that the LMC midwife undertake further training, and that the Midwifery Council of New Zealand reinforce to all midwives the importance of consistently and appropriately applying the Referral Guidelines.
Neither the midwives, the hospital or the DHB were named in the report.
The case happened two years ago.
The Midwifery Council has issued a statement, saying it had today posted a reminder to midwives about the use of the Referral Guidelines on its website and as well as sending it individually to all practising midwives.
"The guidelines protect everybody. It is one of the ways we keep mothers and babies safe, and how midwives work with their obstetric, paediatric and other colleagues when cases become complicated. We cannot eliminate all risk but we can do everything possible to make sure tragedies like this don't happen again," Associate Professor Judith McAra Couper, chairwoman of the Midwifery Council, said.
The decision making process by the midwives concerned was "flawed", she said, and "not up to the standard we expect of all midwives".
"Our sincere sympathies go out to the mother and the wider family of the baby," Associate Professor McAra Couper said.
"The council absolutely supports the mother in her wish that she does not want this tragedy to happen to anyone else.
"We're confident that the majority of midwives follow the Referral Guidelines, consulting with specialists when cases become complex. The council is clear that this is the standard expected of every midwife and will hold midwives to account if they do not maintain these high standards."