A midwife has been faulted over her care of a woman whose baby girl, her first child, was stillborn.
The cause of death was an inflammation of foetal membranes from bacterial infection - referred to as chorioamnionitis - and inflamed blood vessels and blood clots.
The girl weighed 2375g, said the report by Health and Disability Commissioner Anthony Hill.
He has told the midwife, who is not named in his report, to undergo retraining in record-keeping, documentation, informed consent and care for women in labour. He asked the Midwifery Council to review her competence and told the midwife to apologise to the woman.
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The patient, identified only as "Mrs D", was aged 32 when she was pregnant with her first child in 2014.
Mr Hill said the midwife breached the code of patients' rights and failed to follow up advice and ascertain if a 32-week scan had been done.
And on the evening before the delivery, she failed - after the husband told her his wife was experiencing stronger labour pain - to arrange a full assessment, either in the patient's home or at the hospital.
Mr Hill said the midwife had also breached professional standards by failing to document significant events.