About midnight, the registrar called the specialist at home. They discussed a plan to try a forceps delivery and if that failed, a caesarean operation.
Their recall differs on how this was to be done. According to Mr Hill's report, the registrar understood she was to carry out the procedures unsupervised; the specialist understood he was to attend.
The specialist arrived at the hospital at 12.40am - just as the registrar was starting with the forceps in theatre - but he was diverted to another obstetric emergency.
The registrar said she decided to proceed because "I did not consider that I could wait to deliver due to the evidence of fetal compromise", and because she knew the specialist was dealing with the other emergency.
"Unfortunately, I did not appreciate the complexity of the case and therefore did not recognise that I was out of my depth."
She pulled once on the forceps with a contraction but the baby did not descend. She left to scrub for the caesarean at 12.42am and about six minutes later made the incision.
However, the baby was jammed tight in the pelvis. The woman was given a drug to relax the uterus and a midwife was asked to "push up from below to dis-impact the baby's head". The head was released but still the baby could not be extracted.
A second dose of the drug was given and at 1am the specialist arrived and was able to flex and deliver the baby's head. At 1.02am the baby was born, white and floppy, with the umbilical cord wrapped around her neck and shoulder. No heart beat was audible. She was resuscitated and taken to the intensive care unit, but she had suffered a brain injury from the lack of oxygen during birth and later died.
Mr Hill faulted the DHB for failing to ensure its policies were complied with. An extra specialist should have been called in when another obstetric emergency occurred. Second, although a meeting of senior medical staff had decided the registrar, a third-year trainee but new to the DHB, would need direct supervision for caesareans, there was no evidence she was formally notified of this or told what procedures she could do unsupervised.
At her previous hospital she had been approved to do caesareans unsupervised.
The DHB told Mr Hill: " ... this event does not reflect a general breakdown of current and existing practices in our tertiary level maternity care unit."
The commissioner said oversight by specialists provides a safety net. "As the senior supervising clinician, the obstetrics consultant had a responsibility to ensure that his instructions were communicated clearly, and that they were understood."
Mr Hill said he was concerned at how long it took the the on-call specialist to travel the 1.3km from his home to the hospital - 20-30 minutes. He had been delayed by a call from a midwife about the second emergency.
The specialist was unaware of the DHB's requirement that an obstetric specialist can get to the hospital within 20 minutes.
The DHB said last night that it had apologised to the family and reinforced staff education and orientation.
Drug blunder ended fertility process
A woman's fertility procedure had to be abandoned because she was taking the wrong medication, owing to a mistake by a pharmacist.
Deputy Health and Disability Commissioner Theo Baker found the pharmacist had breached the code of patients' rights.
The woman was to have embryos transferred into her uterus as part of in-vitro fertilisation treatment. In preparation she was prescribed a medication called oestradiol valerate.
The prescription was faxed to a pharmacy, where a pharmacist entered the first four letters, "oest", into the pharmacy computer system to produce a label.
The medication name "oestriol" came up on the screen and the pharmacist, in error, selected this and dispensed it to the woman.
"It was later discovered that she had been dispensed an incorrect form of oestrogen," the commissioner's office said when making Ms Baker's report public. "As a result of taking the wrong medication, the woman's embryo transfer cycle had to be abandoned."
The woman went back to the pharmacy to return the oestriol and to pick up the correct medication. She spoke to another pharmacist there who apologised and said a computer error had occurred.
Ms Baker said that by failing to check the dispensed medication against the prescription, the first pharmacist had failed to comply with the profession's standards. This pharmacist wrote a letter of apology to the woman after she complained. Martin Johnston
