A newborn died after a midwife made a "bad call" to deliver him alone and then failed to make sure he was breathing appropriately, a coroner has ruled.
Little Tane O'Hagan Brider lived for only two hours, but it has taken eight years for a coroner to rule on why he died so soon after being born.
In a decision released today, coroner Garry Evans ruled the newborn died of a brain injury "due to a failure to establish effective ventilation" following the baby's birth.
It has taken so long for the coroner's inquest to be completed because the first coroner handling the case died and police were asked by the baby's father to see if criminal proceedings could be taken against the midwife responsible for Tane's care.
Police decided late last year that there was no case for criminal action.
The baby's mother, Melissa Brider, had chosen Cheryl Baker to be her midwife and Baker had cared for her through her pregnancy.
Baker was criticised in the coroner's report for failing to call another midwife to assist during the birth and taking too long to respond to the baby's deteriorating condition, both steps which could have potentially have saved Tane's life, the report stated.
A midwife for 22 years, Baker was now employed at the Whanganui Family Planning Clinic.
Brider, who was 18 at the time, was admitted to the delivery suite at Whanganui Public Hospital about 1pm on December 3, 2004.
Apart from some minor complications Brider's labour was normal. She had requested further pain relief at 8.15pm and Baker then administered 50 micrograms of pethidine and 50mg of Fentanyl. Tane was born at 9.45pm.
It is the doses of pethedine and Fentanyl which was given to the mother that could have proven fatal for her baby, who shouldn't have died had he been appropriately monitored, doctors told the inquest.
Brider and the baby's father Robert O'Hagan thought things weren't right from the beginning.
Mother and baby had some skin-on-skin contact before Tane was wrapped in a towel and given to Brider, the coroner's report stated.
Baker then left the room - for how long is disputed - but the coroner says it is likely she was out of the room for about seven to eight minutes.
Brider said she never heard Tane cry and had told Baker three times that he wasn't breathing and was told in return "not to be stupid" and to keep trying to breastfeed him.
Brider recalled that she told Baker again that he was struggling to breath and was told he was fine and that "it'll be because of the medication".
"She said Ms Baker argued with her for about a minute," the coroner's report said. "She then had another look at Tane, grabbed him off her and rushed out of the room."
It was this delay in recognising the baby's condition which most likely proved fatal, one doctor told the inquest.
Baker rushed the baby to the resuscitation room, where Tane was given medication, CPR was administered and the baby was ventilated and a bag and mask ventilation were used.
Other hospital staff had been called to assist and one noted at 10.20pm that Tane was purple, floppy and having difficulty breathing.
He was pronounced dead at 11.23pm.
An autopsy revealed Tane's lungs were poorly inflated and contained amniotic fluid.
On reflection, Baker told the coroner through her lawyer, that another midwife should have been present. Other midwives referred to in the report said it was an "unwritten guideline" that two midwives should always be present.
Baker was not employed by the hospital but could call on the hospital midwife to assist.
The head of midwifery at Whanganui DHB, Lenna Young, said it was "so obvious" that two midwives be in attendance.
She said a midwife should be on alert concerning respiration, especially when a baby had been given pethedine, as in this case.
Young said it was "exceptional" to administer Fentanyl upon request.
Pethedine and Fentanyl are opiates which cross the placenta and can persist in the foetus after delivery, and can affect respiration, Dr Digby Ngan Kee told the inquest.
In retrospect, Baker said Tane's breathing could have been affected by the opiates and because his umbilical cord had been wrapped twice around his neck when he was born, and she shouldn't have left him unobserved for as long as she did.
That decision was a "bad call", she said.
In her evidence, she said she had explained to Brider "that pethedine might cause a problem for the baby" and "in hindsight" it would have been best for her to have called for assistance.