A delay in proper medical care left a four-week-old baby with quadriplegic cerebral palsy and needing 24-hour care for the rest of her life, the Health and Disability Commissioner said today.

Commissioner Ron Paterson's report on the care of "Baby A", released today, criticised the doctor and midwife who were in charge of her care when she became ill in January 2004.

The report found that the baby suffered severe brain damage after a delay in diagnosing group B strep meningococcal disease.

The junior doctor, who works for a private company contracted to Gisborne Hospital's Emergency Department (ED), and the private midwife were ordered to apologise to the little girl's family.

The incident happened on January 4, 2004, when Baby A -- who had not been feeding properly -- was taken to Gisborne Hospital suffering from a high temperature.

The attending doctor, "Dr E" examined the infant, but considered her symptoms could have been from the strong summer heat the region had been having.

At the time, the doctor did not know Baby A's mother had been treated for a group B streptococcus infection during labour.

He said he did consider meningitis as a cause of the fever, but with no other symptoms, he did not realise he was dealing with an "acutely unwell child".

Dr E sent the baby home and advised her family to watch for deteriorating symptoms.

The girl's health did not improve so her mother, Ms A, called her midwife, Ms F, who visited the family's home immediately.

Ms F arrived to the baby twitching and making "fretful noises". She cooled the baby down and told her mother to take the baby back to the hospital if her condition worsened.

The next day staff at the hospital's paediatric department diagnosed Baby A with severe septis and meningitis. A CT scan on Baby A's brain found severe structural abnormalities, the report said.

Tairawhiti District Health head Jim Green said the Board sincerely regretted that systems in place at Gisborne Hospital failed to prevent the tragic outcome.

"In accordance with the commissioner's requirements, TDH has completed the actions required and we are confident that the likelihood of a further case has been further reduced," Mr Green told the Gisborne Herald.

"The networks required have been reviewed and strengthened as part of our understanding of how the series of events took place that resulted in the poor outcome for this child and family."

Mr Green said that while the commissioner's finding was to ensure appropriate services were in place, it was "nevertheless very regrettable that this child's condition was not identified earlier which may have lead to a better outcome".