"It was decided to take the baby to surgery, and an operating theatre was booked," Deputy Commissioner Rose Wall said in the new report.
"However, there was a delay of over three hours in taking the baby to surgery. During this time, the baby continued to deteriorate."
The HDC investigated the delay in getting the baby into the operating theatre.
Wall found the delay resulted from a communication breakdown, which meant there was no review of the care pathway, so the baby did not get the right help in a timely manner.
"Ideally, in this clinical situation the intention would be to get to the operating theatre within about two hours of the decision to operate being made," Wall said.
One doctor found the baby girl's abdomen was tense, and a paediatric surgeon then attempted to relieve some pressure in the child's abdomen.
But Wall said there was no further communication with the duty anaesthetist by the surgical team or Neonatal Intensive Care Unit expediting the baby's theatre time.
"Nor was there any communication from the duty anaesthetist to the surgical team regarding the delays," Wall added.
She said sometimes delays were longer because of resuscitation priorities, specifically to make surgery and anaesthesia safer.
"But in this case, resuscitation was occurring already by the time surgery was decided upon," the Deputy Commissioner added.
She said in reality, it could often take longer than two hours for a baby in this situation to get to surgery.
"Sometimes this is because of the logistics of accessing theatre space at short notice, and of securing the required staff," Wall added in the new report.
The baby girl was booked for theatre at 9.14am one day, and antibiotics were started at 9.25am.
The girl was eventually taken to theatre at 12.30pm, by which time she was profoundly unwell, Wall said.
"At most, with the advantage of hindsight, the significance of the clinical deterioration might have been picked up a few hours earlier, and the antibiotics would have been better administered six hours earlier," Wall said in her report's conclusions.
She said a planned X-ray of the baby's abdomen could have been performed earlier, but it might not have saved the baby's life.
"Even if imaging had been performed earlier, and antibiotics started during the night [and] surgery undertaken earlier, there is no evidence that the eventual outcome would have been different."
Waikato DHB agreed to carry out an audit of wait times for acute surgery in paediatric operating theatres.
The health board also agreed to provide a written apology to the girl's parents.
Other baby deaths
Limna Polly, 35, is haunted by the sound of her precious baby boy dropping on a hospital floor at birth before taking his final breath 90 minutes later.
She remembers lying down screaming for help at Auckland City Hospital's maternity ward for three hours, knowing she was about to give birth and being told by a doctor to "shut up" instead of receiving help.
Polly said no medical staff believed she was giving birth when she'd only been pregnant for 22 weeks and no one intervened to help deliver her baby.
Auckland DHB didn't dispute any part of the family's complaint but said it "didn't meet the criteria" to be reported to an independent body, Health Quality & Safety Commission (HQSC), for a review as "no issues were identified with the medical care". The DHB did not refer the baby's death to the coroner for investigation.
READ MORE OF LIMNA'S STORY: Baby death - Mum traumatised after newborn boy drops on hospital floor
After a seven-year fight for justice, Zoe and Miguel Daza won a major apology from the country's health watchdog for failing to investigate the death of their daughter.
"We finally feel heard and understood ... it feels like a weight has been lifted off of our shoulders," they told the Weekend Herald.
The West Auckland couple were left distraught after the Health & Disability Commissioner (HDC) declined to investigate their complaint about medical treatment leading to the stillbirth of their daughter in November 2013.
READ MORE OF THE DAZA'S STORY: Stillborn tragedy: Health and Disability Commission forced to apologise, re-investigate baby death
Charitha Meepegama lost his wife during childbirth and their newborn daughter four days later is pleading for an investigation into their sudden deaths.
He said his wife Nilakshani (Nishi) Silva underwent an emergency C-section in an ambulance and died a short time later.
The couple's baby daughter, Eliana, was rushed to Auckland Hospital but her grieving father made the agonising decision to switch off life support four days later.The pair were buried together.
READ MORE ABOUT CHARITHA'S STORY: Auckland childbirth tragedy: Mum, baby die - grieving husband begs for investigation
