The DHB said it accepted the report, acknowledged it failed in its duty, and had made changes to make sure nothing like this happens again.
After seven years of trying Ellie was Ruth Toyoshima and her husband's longed-for first child.
But on the night of the birth, three-and-a-half years ago, tragedy struck.
"Everything that could have gone wrong went wrong, with the machines failing, staff not being adequately trained ... we didn't realise the doctors in charge of resuscitation weren't competent at doing that either," Toyoshima said.
"Every step of my hard delivery, something went wrong."
Ellie was born with severe brain damage due to oxygen deprivation, after staff failed to properly monitor her heart rate and she died after six days.
"Had they realised at the beginning that she was in distress and had given me a C-section ... I think she would have survived."
The Health and Disability Commission report, published yesterday, found a pattern of poor care, including equipment failures, lack of staffing, and delays.
After the death the board commissioned an independent external review, which found a number of problems, including a severe staff shortage.
Meg Waghorn of the Lower Hutt Parents Centre said in the wake of the death some women were worried about the care they might receive. She said the responsibility for remedy laid squarely at the feet of the health board.
"I think there has been a loss of trust. That doesn't mean that can't be built up quite quickly with transparency and actual actions being shown," Waghorn said.
"It is disappointing that it seems to be taking a lot of external pressure to get them to act."
Hutt Valley DHB chief medical officer Dr Sisira Jayathissa would not be interviewed.
In a statement, he apologised to the family and said he sincerely regrets the matter.
"We take patient safety extremely seriously, acknowledge that we failed these patients and their families, and accept the Health and Disability Commissioner's findings," the statement reads.
"Following these events, we implemented a range of changes to try to ensure they do not happen again. We are now in the process of implementing all the HDC's recommendations and aim to have this completed early this year."
Ruth Toyoshima said it sounded as though the hospital was moving in the right direction.
But she wouldn't know first hand - she opted to have her second child at Wellington Hospital, where she received "outstanding care".
She and Kazu's now two-and-a-half year old boy Lyoma is healthy and chirpy.
"Full of energy, full of life - he's a laugh. He loves music and transport - he's your typical little boy, he's absolutely lovely."
She said her son had healed a wound in their lives, coming along just 11 months after Ellie.
"I think if we didn't have him in our lives it wouldn't be as easy to have moved on. I think we were really lucky that we were able to have him so quickly, it almost feels like he was a gift from his sister."
The Associate Health Minister Julie Anne Genter was at a public meeting in the Hutt Valley late last year where midwives complained they were at breaking point because of staff and equipment shortages.
She said the region's maternity services were run down under the previous government.
"This government is committed to rebuilding and strengthening our health system, particularly our maternity care," Genter said at the time.
"There has been an independent external review of Hutt maternity services in November 2018 and I have asked the DHB to pay close attention to implementing the recommendations."
-RNZ
