Two babies stillborn in public hospitals had their heart readings misread by midwives - one of whom admitted responsibility and left the profession, the health and disability commissioner has found.
The babies died in separate incidents of complications during induced deliveries in 2007.
Both mothers were overdue and the midwives decided to admit the women to hospital to induce the births. In both cases, the midwives failed to pick up signs of distress from heart-monitoring equipment.
One woman gave birth to a stillborn baby, while the other mother was sent home, only to return the next day and give birth to a stillborn child.
The midwife in the first case admitted having misread the readings to commissioner Ron Paterson's inquiry.
"I am devastated that I observed the ... monitor through the day and failed to identify the seriousness of the readings," she said.
A midwife with nearly 40 years' experience, she stopped practising after the baby's death.
"I felt responsible and accountable for my actions, which I believe contributed to this tragedy. I cannot begin to express my personal sadness and grief for [the parents] and their family and friends."
The report also found the midwife did not adequately liaise with the hospital's obstetrics unit over possible complications. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists said the report highlighted confusion over referral procedures when self-employed midwives brought their patients to hospitals.
Concerns raised last year were being dealt with in the Health Ministry's new maternity care strategy, said Gillian Gibson, New Zealand's college representative. While midwives could use public hospitals, there were no consistent care standards or guidelines over co-operation with hospital staff, she said.
"[We will work with] related maternity professional bodies to improve the referral guidelines and communication so women and their families can be assured of teamwork between maternity practitioners to ensure safe care," Dr Gibson said.
The midwives concerned had been referred to the Midwifery Council of New Zealand for possible disciplinary action, New Zealand College of Midwives adviser Norma Campbell said.
In his report, Mr Paterson said the ministry review was "a step in the right direction".
"Women in New Zealand believe that a safety net is in place if they choose to deliver their baby in a public hospital.
"That belief is illusory if there are barriers (including fraught relationships) to [midwives] communicating important information to fellow health professionals who may be called to assist."
- The Dominion Post