A coroner has found that a newborn baby died because he did not receive effective ventilation following his birth at Whanganui Hospital.
Tane O'Hagan-Brider died about two hours after he was born on December 4, 2004.
His mother, Melissa Brider, has accused independent midwife Cheryl Baker of ignoring her when she first voiced concerns over Tane's condition after he was born.
Ms Baker disagrees, and there are conflicting recollections about what happened in the delivery room and subsequent attempts to resuscitate Tane.
An inquest was held into his death, the findings of which were released by Whanganui Coroner Garry Evans today.
He found that the cause of death was a brain injury due to failure to establish effective ventilation following his birth.
Tane's family contend he had trouble breathing from the outset and appeared to be blue and floppy. However, Ms Baker recorded the baby's Apgar score - a measure of a healthiness after birth - as a nine out of 10 a minute after he was born, and it remained nine when he was rescored five minutes later.
Fifteen minutes later, however, Tane had collapsed and was rescored as a four. In the intervening time, Ms Baker had left the room to attend to the placenta and get an ice pack for Ms Brider. How long she was gone was also under dispute by Tane's family.
Coroner Evans found that it was more likely than not that she was out of the delivery room for 7-8 minutes.
On direct evidence of Ms Baker, a further five minutes elapsed before resuscitation began.
The coroner found that Tane's state of respiratory distress began to evolve before Ms Baker left the room and continued for a further five minutes following her return.
Giving evidence, Ms Baker said if she had considered Tane was going to "go flat" she would never have left the room.
She had done so at the insistence of a family member, who wanted to take the placenta and leave.
Asked why she didn't call for another midwife to go to the room while she was out, she said the other midwife there had already told her she would be in another ward, and wouldn't be in the office if the bell rang.
"At the time it might have been a bad decision ... In retrospect, yes it was a bad decision," she said.
Tane's family gave evidence that he was in distress before she left, but Ms Baker said they all gave differing versions, 12 months after it happened.
Police decided not to lay charges against Ms Baker or anyone involved in Tane's treatment.
Ms Baker could not be reached for comment.