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The Health and Disability Commissioner has criticised the West Coast District Health Board after lack of care by three midwives left a newborn boy with permanent neurological problems.
Commissioner Ron Paterson also criticised the DHB over the subsequent delays and handling of the complaint into the case.
When the boy, known as Baby A, was born in 2004, he developed hypoglycaemia, or low blood sugar, after he stopped feeding normally in the two days after his birth.
Mr Paterson said the baby, at the lower end of the normal weight range, was vulnerable to hypoglycaemia as his mother, Ms A, was a heavy smoker and taking antidepressants during her pregnancy.
An independent adviser to Mr Paterson, midwife Nimisha Waller, said that as Baby A's weight was still inside the normal range he was not considered to be at risk of hypoglycaemia and did not get regular blood glucose monitoring.
She said all the midwives failed in developing a plan of care on a daily basis and did not recognise a change in Baby A's feeding pattern which resulted in the condition.
Mr Paterson said the combination of risk factors meant the midwives should have immediately monitored blood sugar levels and monitored feeding.
The three midwives have since reviewed their practice and written apologies to Ms A for the lack of care. The DHB has also written an apology to Ms A and is to audit its neonatal policies in regard to low-weight or at-risk babies.
NZPA