A baby girl died after a staff shortage at the Waikato District Health Board (DHB) delayed possible life-saving treatment.
This was one of several findings from a Health and Disability Commission report released on Monday.
It found the DHB was in breach of the Code of Health and Disability Services Consumers' Rights for the care it provided to the newborn baby in its neonatal intensive care unit (NICU).
The report says the DHB had inadequate staffing levels overnight, staff showed a lack of critical thinking, it failed to undertake an adequate assessment of the baby after she started deteriorating, antibiotic treatment was delayed and there weren't adequate medical records documented.
The baby's mother - who was in her late teens - gave birth at home in 2017, but the baby appeared "floppy, unresponsive, and blanched" and was rushed to the NICU.
It was found the baby was born with perinatal hypoxic-ischaemic encephalopathy (HIE) and was treated for this on arrival at hospital.
But the baby developed neonatal sepsis on day four. Her condition then "deteriorated rapidly", the report says, and she subsequently died from the infection the next day.
The grandmother of the baby filed a complaint on behalf of her teenage daughter to HDC.
After the investigation, Health and Disability Commissioner Anthony Hill was critical of the inadequate staffing levels overnight, the lack of critical thinking from staff, delayed treatments and not keeping medical records up-to-date.
He says in the report the baby was becoming septic by 1am on day five, but there was insufficient assessment of the baby and antibiotics weren't given until 12pm.
"Waikato DHB staff displayed a concerning lack of critical thinking when [the baby's] condition deteriorated. The failure to recognise the baby's worsening condition meant that antibiotics were not commenced until midday on day five," Hill says.
"Overall, I find that Waikato DHB failed to respond adequately to a deteriorating situation and, accordingly, breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights."
Hill recommends the DHB formally apologises to the baby's family. He also recommends the DHB introduces an education programme for NICU staff about the signs of possible infection, and about handover and documentation, as well as reviewing staffing levels in the NICU and its procedures for "Early Onset Neonatal Infection Prevention".
