A midwife faces possible legal action over seriously poor care that ended in the death of a newborn baby.
Health and Disability Commissioner Anthony Hill released his report on the 2009 case on Monday.
The report names no one but Denise Simpson-Vogan from Hamilton, who has confirmed she was the mother.
Having had difficulties with her first birth, Ms Simpson-Vogan was told that she would need continuous fetal monitoring for subsequent labours.
She said she accepted this but the midwife turned off the heart-rate and rhythm monitor, saying Ms Simpson-Vogan was unhappy to be restricted.
The baby, Axton Mead, was born pale, floppy and unable to breath and died soon after.
Mr Hill said continuous monitoring was needed for the risky birth and the care was seriously suboptimal.
He's referred the midwife for possible legal action and whether that proceeds will be known in the next two to three weeks.
The midwife is no longer practising.