Hutt Valley District Health Board's maternity ward has been slammed for what is being called a "pattern of poor care" for babies and their mothers.
Commissioner Rose Wall says the DHB failed to properly monitor the heart rates of two babies during labour in 2017, leading to the death of one and brain injury in the other.
Ms Wall says inadequate fetal heart rate monitoring is a recurring theme across complaints to the Commissioner nationwide and she's worried training is not mandatory.
She spoke to our reporter Paloma Migone about the cases.
In a statement, Hutt Valley DHB said it accepted the findings and had apologised to the patients and their families. The DHB says it is in the process of implementing all of the HDC's recommendations.