An anaesthetist could face legal action for refusing to give a woman adequate pain relief during a Caesarean birth.
Health and Disability Commissioner Anthony Hill said there was a striking lack of empathy shown towards the woman, who is now terrified of having another child.
The anaesthetist gave the go-ahead to the obstetrician to proceed with the surgery, despite the woman saying she still had feeling on one side, and during the surgery was in agony.
Mr Hill said the anaesthetic dose was too low and the anaesthetist should have corrected it. The obstetrician performing the surgery also knew that the patient was in considerable pain, but did not speak up.
"It was clear in the medical opinion of the obstetrician that the patient was in pain, and that should have been addressed - it's as simple as that.
"It was a harrowing and awful experience for this woman and wholly avoidable, and ought to have been handled with greater professionalism and greater confidence by those caring for her.
"That's why there is accountability for these two. Bt the short point is, the patient always comes first - and on this day the people caring for her let her down."
Neither the doctors nor the hospital involved have been named in Mr Hill's report.