The Health and Disability Commissioner has criticised a midwife who turned around an ambulance while it was taking an expectant mother to hospital for an emergency birth.
Anthony Hill says the midwife didn't realise the woman was having a breech birth because she didn't assess her properly.
She also turned back the ambulance while it was on its way to hospital because she believed that the woman was about to give birth.
Mr Hill said another midwife back at the maternity unit then identified it was a breech birth and got the mother back in the ambulance.
"This woman should have been assessed on presentation and should've been urgently taken to hospital for a caesarian section. Because this is a serious breach, I have referred the midwife to the Director of Proceedings, who may consider whether or not to take disciplinary proceedings."
The baby suffered a lack of oxygen during birth and has delayed communication development, he said.