The midwife, doctor and district health board involved in delivering and caring for a baby who died 22 hours after being born have been heavily criticised for the poor care given to her and her mother.

The woman's midwife was found to have mismanaged the process and did not make the doctor aware of the baby's distress, causing unnecessary delays, while the paediatric registrar gave five times more than the recommended amount of midazolam to the sick baby, a report from Deputy Health and Disability Commissioner Rose Wall has found.

The DHB was also found to have failed in several aspects to provide adequate care to the baby and should have had better processes in place to confirm the transfer of care from a lead maternity carer (LMC) to the DHB.

The mother was admitted to hospital to give birth to the baby, but after the baby's head was mistaken for the vaginal wall, she ended up pushing for two hours when not fully dilated.

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Wall faulted the midwife and DHB for not giving her a comprehensive vaginal examination which would have indicated this.

She also found the baby's fetal well-being needed to be better monitored and would have indicated fetal distress earlier.

Wall said the lead maternity carer should have been clear about when she had transferred the woman's care over to the hospital, as this led to some omissions in care by the DHB and uncertainty around who was responsible for what.

After meconium was found in the mother's waters and the baby's heart beat continued to accelerate, a decision was made to deliver the baby by caesarean almost 10 hours after the mother was admitted.

At birth, the baby was unexpectedly pale and struggling to breathe and required intensive care treatment.

Wall found some of the neonatal care given to the newborn, who had seizures and low blood pressure, was poor, including an overdose of a drug - five times more than required due to miscommunication between the doctor and nurse about its concentration.

While it could not exclude that the overdose contributed to the baby's death, it was unlikely given the baby's deteriorating condition. The baby died when just 22 hours old.

The HDC ruling found the self-employed midwife, the DHB and paediatric registrar breached the Code of Health and Disability Services Consumers' Rights (the Code) and they have all made written apologies to the family.

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The DHB was recommended to improve its guidelines around the transfer of care from primary to secondary carer and the LMC midwife undertook a number of actions to meet the requirements of the Midwifery Council competence programme.