A midwife has been criticised for a series of poor care decisions - including text-messaging her client - at an inquest into the death of a boy shortly after he was born.
Hastings coroner Chris Devonport said texting appeared to be an "inappropriate" way for midwives to complete clinical assessments.
The failure to make direct voice contact with the expectant mother was one of several errors highlighted in the coroner's finding, released today, on the death at Hawke's Bay Hospital.
The cause of death was given as an insufficient blood flow to the brain, caused by a lack of oxygen, known as perinatal asphyxia.
A report by two midwives for the inquest said text messaging between the midwife and her client "prevented adequate clinical assessment".
It also criticised an obstetrics registrar for her part in poor communication with the midwife and failing to read a fetal heart monitor properly.
The finding said that about 7.45am on June 22 last year, the client texted her midwife after losing blood and feeling discomfort. The midwife texted back, then visited the woman at home at 8.30am, where her blood pressure was found to be elevated.
She left a few hours later, asking the woman to contact her if she had further bleeding or headaches.
About 11am the midwife received another text after the patient had further bleeding and clots. An on-call registrar was contacted and the couple arrived at hospital at 1.30pm.
A specialist obstetrician commissioned to investigate the death said that in the ensuing four hours, before an emergency caesarean section at 5.16pm, the midwife misread "grossly abnormal" changes in a fetal heart monitor, which were noticed only at 4.40pm.
He said the texts were "unlikely to lead to a correct diagnosis", the midwife had not properly consulted specialists and her client should have been transferred to hospital by ambulance. "I think that [midwife] did not meet an acceptable standard of practice in this regard."
The specialist also said the obstetrics registrar present failed in her care after she too incorrectly misread the heart monitor.
A lawyer acting for the midwife said had she been aware of an "apricot-sized clot" described in later reports, or the patient's increased pain, she would have transferred her earlier.
"In hindsight", she accepted an earlier transfer to hospital would have been prudent, but she also knew her client wanted a home birth, so wanted to assess whether this could still occur.
The midwife has refused to comment.
Mr Devonport, who suppressed the names of the family, midwife and doctors, described the tragedy as a "lack of awareness of a clinical situation" and a failure to notice abnormalities of fetal distress that "may have saved the life of the baby".
He said texting was not a tool for clinical assessments, and should not be a substitute for direct voice contact.
The boy's parents said they did not want to get involved in the blame game. "There's nothing anyone can do to bring him back," the father said.
Getting angry would only make things worse. "The mistakes have all been adequately addressed, and we think something positive has come from this with the recommendations that have been made."
While the couple had not enlisted the same midwife for a baby due next month, he said he didn't "have a problem" with her still practising.
Nor did he have an issue with texting. "We didn't think it was inadequate at the time - it's the world we live in."