A midwife put a pregnant woman and her unborn baby at risk by not taking health complications seriously enough, the Health and Disability Commissioner has found.
Commissioner Antony Hill criticised the midwife for not dealing urgently with the matter.
The 26-year-old woman experienced symptoms of pre-eclampsia, a condition which raises a pregnant woman's blood pressure and can reduce oxygen supply to the baby.
The report found that during an antenatal check, the midwife recorded the woman's high blood pressure, but did not take action.
The woman, who was full term, went into labour and went to hospital, where her midwife still failed to treat the pre-eclampsia.
An on-call obstetric registrar took over the woman's care and dealt with the symptoms. She delivered a healthy baby.
The commissioner referred the midwife to a lawyer and the Midwifery Council.