A midwife failed to provide appropriate care to a young woman during her pregnancy and birth, after her baby girl died shortly after birth.
A report by the Health and Disability Commissioner said the young woman, who was pregnant with her first child and wished to have a home birth, had chosen the services of a registered community midwife as her lead maternity carer. She also had a back-up midwife.
On the day the young woman went into labour, her midwife arrived at her home with a second back-up midwife.
The baby was later born with her umbilical cord wrapped around her neck several times. The midwife did not have an oxygen cylinder and the second back-up midwife had forgotten her home birth equipment.
Attempts to resuscitate the baby showed little improvement, and an ambulance was called where the baby was given advanced resuscitation, and then transferred by helicopter to the neonatal intensive care unit.