An inexperienced midwife is being blamed in part for a series of errors that led to the death of a newborn baby and nearly claimed the life of his mother.
A coroner's findings into the 2009 death of baby Adam Barlow has revealed a catalogue of errors by Hamilton midwife Jennifer Rowan.
Adam was declared stillborn, but a coronial inquest was ordered after his parents, Linda and Robert Barlow, read medical notes indicating their son had shown signs of life.
The Barlows blamed the inexperience of Ms Rowan, who had been a midwife for seven months at the time, as a major factor in his death.
Mrs Barlow's placenta tore from her uterus, and she stopped breathing after being given an epidural.
She had an emergency caesarean but was bleeding profusely internally.
She had a heart attack, needed cardiac massage for six minutes and was then taken to intensive care and placed on life support, not knowing that her little boy had died.
As a result of what happened Mrs Barlow was unable to have any more children herself but the Barlows have conceived a child with in vitro fertilisation and a surrogate mother.
In his findings, released yesterday, Coroner Gordon Matenga said Ms Rowan was unable to refer to any previous experience during her training or in her brief practice to a woman with Mrs Barlow's issues.
"She was reluctant to accept her inexperience and there was a distinct reluctance from the midwifery experts to accept that experience has a significant role to play in producing competent and confident midwife LMCs (lead maternity carers)," he said.
It was "of concern" that Ms Rowan ignored River Ridge birthing centre policies that required specific heart monitoring of the patient before and after she administered the controlled drug pethidine.
She then sent Mrs Barlow home after she gave her the drug with no further assessment. Mrs Barlow returned three hours later by ambulance, fully dilated and distressed.
Mr Matenga said baby Adam's death by intrapartum asphyxia was brought on by several factors including Ms Rowan's failure to recognise that Mrs Barlow's labour was not normal.
He also found Ms Rowan did not convey any urgency, verbally or in writing to Waikato Hospital staff when they arrived via ambulance.
He found more shortcomings by Ms Rowan and hospital staff to recognise the immediacy of Mrs Barlow's situation and hasten the delivery of baby Adam.
There was a breakdown in communication over the transfer of care that arose from staff failing to follow referral guidelines.
"It was submitted to me ... that uncertainty on the part of the LMC and hospital staff resulted in neither the LMC nor the hospital midwives taking control of Linda Barlow's labour in the absence of Dr Gill from the delivery suite," he said.
"Dr Gill acknowledged her inexperience and accepted her responsibility. Jennifer Rowan, however, did not acknowledge her inexperience and neither did she accept any responsibility."
Mr Matenga made several recommendations, including amendments to referral guidelines for midwives and the review of midwifery training to ensure training was consistent with those guidelines.
Midwifery Council spokeswoman Leigh Bredenkamp said some of Mr Matenga's recommendations were now in practice.
Ms Bredenkamp said graduates benefited from the support of more-experienced midwives, and Ms Rowan could have been better supervised at the time.
Waikato DHB chief operating officer Jan Adams said an internal investigation revealed areas for improvement that had been actioned and noted by the coroner.
Herald inquiries show Ms Rowan was working as a midwife for "young mums" with the Counties Manukau District Health Board until this year but is now on maternity leave.
Robert Barlow said the moves to improve mentoring for midwives was a good step "as long as they are followed".
"We just presumed that all midwives were equally trained and we had automatically thought a midwife working self employed, independently in the community would have had some experience of being a junior midwife after they had completed their training.''
"We believe that clinical supervision is everything and experience is everything as well,'' he said.
The Weekend Herald revealed last month how Mrs Barlow was no longer able to have a child as a result of what happened during Adam's delivery, and so had turned to in vitro fertilisation and a surrogate mother.
Mrs Barlow, a physiotherapist, said the new baby, which was genetically hers and her husband's, would not take Adam's place.
"This baby is a different person. We would always say that we had three beautiful children."