A Taranaki District Health Board obstetrician and midwife face possible disciplinary action because of a botched childbirth that left a baby with long-term health problems.
The hospital birth went wrong after the woman about to have the baby developed a temperature and began to feel unwell.
In his report on the case, Health and Disability Commissioner Anthony Hill says the obstetrician considered an instrument delivery, but assumed the patient did not want it and directed the midwife to use other methods of bringing on contractions.
When the baby was born, it was pale, floppy and covered with meconium. Mr Hill says the obstetrician tried to revive it and did not agree to transfer to a neonatal unit until asked three times by the midwife.
The baby was flown to another hospital and remained in poor health.
Mr Hill found multiple failures and has referred the matter for possible legal action.
The DHB's chief medical adviser, Greg Simmons, told Radio New Zealand's Checkpoint programme today that it accepts the commissioner's findings.
"I think the attitude of the obstetrics staff and their relationship with the midwife staff has improved significantly over the last two years."
He says the obstetrician is no longer practising.