The Waikato District Health Board (WDHB) has accepted a coroner's report which found hospital staff, along with a midwife, contributed to the death of a baby boy soon after he was born.
Adam Barlow was delivered by an emergency caesarean section at Waikato Hospital in October 2009.
He was floppy and unresponsive, but a faint heartbeat was heard and aggressive attempts were made to resuscitate him.
However, he did not survive and his mother, Linda Barlow, was left fighting for her life.
In his findings, released on Wednesday, Coroner Gordon Matenga found that Mrs Barlow's midwife, Jennifer Rowan, failed to recognise that the progress of labour was not normal.
She also failed to make hospital staff aware that Ms Barlow's situation was precarious.
Mr Matenga found that both Ms Rowan and hospital staff failed to recognise the urgency of Mrs Barlow's situation and expedite delivery.
Further, both parties failed to review and properly interpret Adam's heartbeat and Ms Barlow's contractions.
Mr Matenga recommended the board require its obstetrics registrars to consult with their supervisor in respect of every woman that was transferred from primary care.
Clinical director obstetrics Dr Penelope Makepeace said the hospital had taken the recommendation on board.
"We accept we need to support junior staff and are working with them as to how that will happen.
"We also note that new referral guidelines have given greater clarity in how transfers should be made and I welcome the incorporation of emergency management transfer guidelines."
Chief operating officer Jan Adams said an internal investigation found some areas which needed to be improved at the hospital.
"The coroner accepted the findings of our internal investigation, which was carried out as part of the national serious and sentinel event reporting process," she said.
"Many of the recommendations made by the coroner have already been actioned by the DHB and the DHB will work to ensure that we continually improve the services that we offer to our patients."
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