"The back-up midwife advised the woman to go back to bed, have an early breakfast in the morning, and call her afterwards if she still had not felt the baby move," Mr Hill said.
The woman phoned the midwife after breakfast to say she still had not felt her baby move. They arranged to meet at the hospital.
After an examination by the on-call consultant at the hospital, the woman was advised her baby had died. She gave birth to a stillborn baby boy the following day.
Mr Hill's investigation found the advice the back-up midwife gave to the woman was inappropriate, particularly given the woman's additional risk factors -- the concerns about the baby's growth, and the fact that the woman was overdue.
Even in the absence of any particular risk factors, the back-up midwife's advice "displayed a lack of care and skill", Mr Hill said.
The standard of care provided by the back-up midwife to the woman was a severe departure from expected standards, and in breach of the Code of Health and Disability Services Consumers' Rights, he said.
The back-up midwife was referred to the Director of Proceedings for consideration of possible further legal action.
In a separate decision, Mr Hill has faulted the Canterbury District Health Board after a woman's healthy fallopian tube was removed after it was mistakenly diagnosed as abnormal.
The woman had a history of an ectopic pregnancy, which had resulted in the removal of her right fallopian tube.
She became pregnant again and after having an ultrasound, she was referred to the public hospital with a suspected ectopic pregnancy.
She agreed to the removal of her remaining left fallopian tube after she was told it was abnormal. The woman repeatedly asked for foetal tissue returned to her following surgery, Mr Hill said.
However, following the removal of the tube, it and the pregnancy were found to be normal.
The woman decided to terminate the pregnancy because of her concerns the surgery may have harmed the foetus.
As well as removing a normal fallopian tube, staff also destroyed the fetal tissue despite the woman repeatedly asking for it to be given back to her.
The cumulative effect of a number of individual errors resulted in the woman receiving suboptimal care, Mr Hill said.
The DHB also breached the woman's right to make a decision about the return or disposal of any body parts or bodily substances removed or obtained in the course of a healthcare procedure.
