While being transported to hospital, the baby was not monitored. The midwife was seated one metre away from the baby and was unable to lift the baby's chin to increase his airflow.
During the ride, ambulance staff sat in the front and did not assess the baby, the investigation found.
Once the baby arrived at the hospital he was hypothermic and grunting. He was then diagnosed with a brain injury due to the lack of oxygen flow to his brain.
In her report, Commissioner Rose Wall said the ambulance provider told HDC an agreement had been made with the New Zealand College of Midwives that if a midwife is present, the midwife is in charge of the situation, unless the midwife were to hand over to ambulance staff.
However, the Midwifery Council of New Zealand said that it was not aware of the agreement.
Wall said she was "satisfied" there was no individual providers were solely responsible for the poor care of the newborn.
But she said a "wider systemic change" is needed to ensure similar cases do not occur.
Following this investigation, she has written to the Midwifery Council of New Zealand, the New Zealand College of Midwives, ACC, the director-general of health, the Paediatric Society of New Zealand, Ambulance NZ, and HQSC expressing her concerns.
Wall recommend these groups work alongside each other to address issues and improve the safety of patients.
She also made five suggestions for improvement to be used as a starting point to initiate conversations and promote further collaboration between the groups.
"I hope that these suggestions will go some way towards strengthening the cooperation and co-ordination between midwifery and ambulance services within New Zealand."
