An eight-day-old baby required hospital treatment after a midwife attempted to remove tongue-tie by cutting the skin under its tongue with scissors.
The lactation consultant cut too deep and bleeding from the wound could not stopped, which required a trip to hospital.
The Health and Disability Commission launched a review into the incident and found the consultant breached the Code of Health and Disability Services Consumers' Rights.
The baby's mother rang the consultant, who was also a registered midwife, because she was having difficulty while breastfeeding.
The consultant identified the baby had tongue-tie and offered to perform a frenotomy on the child.
Without discussing the non-surgical alternatives with the mother, the consultant performed the procedure which involves cutting the skin under the tongue with scissors.
The mother was distressed and wanted to check her options with her LMC midwife but said she felt rushed into the procedure by the consultant.
Following the procedure, the baby started bleeding from the wound and could not be stopped and was required to be taken to hospital by ambulance.
Doctors repaired the cut in theatre and noted the incision from the consultant was deep and well into the tongue base.
They also found the cut caused significant bleeding from a branch of the lingual artery and was more resection than was needed.
Deputy Health and Disability Commissioner Meenal Duggal released a report into the incident and deemed the consultant to be in breach of the Code.
Duggal also found the consultant also failed to provide information for a consumer to receive and make an informed choice about an operation.
The consultant was required to report to the Health and Disability Commissioner outlining her discussion with an ear, nose and throat specialist and the changes made to her practice as a result.
Duggal suggested the consultant provide a letter of apology to the family of the baby and recommended the Ministry of Health consider formulating a consensus position on the efficacy of frenotomies.