A newborn baby will become paralysed on one side of its body after an oxygen tank used to resuscitate it wasn't turned on.
In a report released on Monday, Deputy Health and Disability Commissioner Rose Wall highlighted several issues with the care the baby received.
The issues occurred more than five years ago when a woman in her 20s gave birth to twins.
At 28 weeks pregnant the woman visited a sonographer for an ultrasound. The reporting radiologist reviewed the sonographer's worksheet and images and found issues but did not document this in his report. He also did not follow up after the scan.
Three days later, the woman experienced abdominal pain and was admitted to hospital where the obstetrician performed an ultrasound and noted that it was obvious the woman was pregnant with twins. The obstetrician then immediately recommended an urgent C-section.
One baby was born healthy but the other was born floppy with no heartbeat and needed immediate resuscitation.
According to the report, theatre staff had not been told that the woman was having twins and had used a small room with only one resuscitaire, meaning a second had to be located quickly.
Despite three attempts to intubate the baby, there was no improvement in its ventilation. After the last attempt, staff noticed that the oxygen cylinder had not been turned on. After the machine was turned on the baby's saturation levels began to rise but not to a high enough level.
The staff then called a main centre Neonatal Intensive Care Unit [NICU] and were told the tube used to incubate the baby was too small. The staff agreed to wait until the NICU team arrived and changed the tube.
Once the tube was changed the baby's oxygen levels improved to the appropriate level. But the baby was subsequently diagnosed with right hemiplegia - a condition that leads to paralysis on one side of the body.
The woman was not advised about the equipment issues until her first paediatric appointment.
In the report, Deputy Commissioner Wall found that the radiologist's report was inadequate, and was critical that he did not undertake any follow-up action after the scan.
Wall also found that the DHB did not have in place appropriate policies to ensure the early involvement of a paediatric consultant for an urgent or emergency birth.
She also found that the operating theatre was not prepared for the delivery of twins.
"I consider that at the time of the incident, [the DHB] had several systemic issues," said Wall. "This affected the care provided to [the woman] and [twin 1]."
Wall recommended that the radiology service report back to the Health and Disability Commission [HDC] about the changes it implemented, and that the radiologist apologise to the woman.
She noted that since the birth the DHB has commissioned an external review of its maternity services and has taken a number of steps to improve its systems.
In response to the recommendations, the DHB apologised to the woman and updated HDC about the steps taken to carry out the external reviewer's recommendations.
These included increasing staffing in the women's health area, reviewing equipment, and implementing Care Capacity Demand Management in Maternity.