The Health and Disability Commissioner has found the care of a mother and her baby, who was born stillborn, was seriously compromised.
The Commissioner found the midwife and the Hutt Valley District Health Board were in breach of the Code of Health and Disability Services Consumers' Rights.
In 2014, the woman's midwife recorded she was obese on the BMI scale and likely had Hepatitis C.
She should have referred the woman to a specialist due to her weight, but did not, to avoid embarrassment.
During labour, the doctors in charge were not told of the woman's complications or that she had since developed a urinary tract infection.
The senior doctor said if they had been notified, the woman would have been considered high risk and may have been treated differently.
It was also found that for a time the heartbeat being recorded as the baby's was actually the mother's.
The midwife said she had since changed the way she dealt with referrals.
"I have changed my practice around BMI referrals, and without trying to scare women, I share the risks more completely associated with an increased BMI and put the referrals in at booking with BMI over 35 and offer women the chance to attend the secondary care appointment and offer to attend with them so they feel supported and less intimidated or embarrassed."
The Midwifery Council of New Zealand undertook a formal review of [the midwife's] competence and required her to undertake specific training and practice under supervision from November 2015.
The council advised that [she] complete the programme of education satisfactorily and that the monthly supervision reports indicated good progress against various goals. Supervision ceased in November 2016.
An advisor to the Commissioner John Short noted that there had not been adequate support and backup for a junior doctor, who was left in charge for long periods of time.
"There was a conspicuous lack of senior medical involvement in the patient's care … this inevitably raises concerns regarding the supervision of junior doctors in the Obstetrics and Gynaecology department at [Hutt Valley] DHB.
"The service appears to have been relying on inexperienced doctors, often working in isolation with barriers to them obtaining help from their seniors.
"The organisation failed to create an environment that ensured RMOs (Resident Medical Officers) were appropriately supported by more experienced specialists.
"As a result, patient safety was compromised. In [this] case... my opinion is that this constitutes a severe departure from the expected standard of care."
The Commissioner recommended the DHB review the way information was handed over between healthcare professionals and to make it clear to all staff how to access the on-call registrar.
The DHB also undertook an internal review and has made a number of changes, including recruiting two more senior doctors, making it easier for junior doctors to access advice and help from senior doctors and interpretation cards by all CTG (cardiotocography ) machines to make it easier for staff to monitor heartbeats.
DHB chief executive Dale Oliff accepted the report's findings.
"We have sincerely apologised to the family for the tragic outcome they suffered and acknowledge our systems and processes failed to protect them.
"We are confident the improvements we have made to our systems and processes will support our clinicians to provide safe care.
"We acknowledge this must be very painful for the family at the centre of this event and in respecting their privacy, we will not be commenting further on this matter."