Failure to get breathing established caused the death of a baby boy at Whanganui Hospital in December 2004, Coroner Garry Evans has found.
Tane O'Hagan-Brider died less than two hours after his mother, 19-year-old Melissa Brider, gave birth to him on December 3.
Though Coroner Evans' report is critical of the role of independent midwife Cheryl Baker in the birth, her actions were not found to be a breach of her duty of care, or of any professional standard.
At the 2011-12 coronial inquiry police were invited by Ms Brider's lawyer, John Rowan QC, to investigate the birth with a view to prosecutions. They decided not to take any action against Ms Baker or anyone else.
At the time of baby Tane's death, Ms Baker was a midwife with 15 years' experience. She was using Whanganui Hospital facilities for the birth, under the terms of an access agreement. The agreement made her fundamentally responsible, but able to ask for help.
An inquest into the death was opened by then Whanganui Coroner Colin Riddett in 2004, but he subsequently died. It was next opened by Wellington Coroner Garry Evans, and heard over five days in Wanganui in December 2011 and February 2012. Findings were reserved while police decided whether to investigate further.
In the findings Coroner Evans apologised for the long delay.
In 2004, Ms Brider's birth was proceeding without major problems. She asked for and received two batches of opiate painkillers, one of them in the second stage of her labour. Opiates given at a late stage can affect a baby's breathing.
The final stage of labour happened quickly, and when Tane was born he had the umbilical cord wrapped tightly twice around his neck.
Ms Baker gave him a high health score soon after birth, but after she left the room his situation quickly got worse.
The baby's mother and family members told her he was not well, but she did not immediately take action.
When she returned from dealing with the placenta, baby Tane was having trouble breathing, and she called for help.
Evidence about the crucial period of time from birth until help was called was conflicting, but Coroner Evans came to the conclusion that Ms Baker was probably out of the room for seven to eight minutes, and then it was another five minutes after her return before baby Tane got help with his breathing.
Despite the efforts of several staff members, that help came too late.
Experts giving evidence said it was unwise of Ms Baker to leave the room for so long, given that the baby's breathing problems could have been expected because of the rapid final stage of labour, the cord having been around the baby's neck and his exposure to the opiates in his mother's system.
Given that, and conflict between the baby's father and grandmother, she would also have been wise to have another midwife present during the birth.
At the coroner's inquiry, Ms Baker accepted both those things.
There were also questions about the manner used to call for help, as at least one of the methods had no effect at that time.
Getting help would have been easier if there had been a telephone in the room.
Contacted by the Chronicle, Ms Baker did not wish to comment on the matter. She has not worked as a midwife since 2010.
The Chronicle was unable to locate the baby's mother or father for comment.
The 2004 death was reviewed by Whanganui Hospital's Obstetrics Review Committee. Whanganui District Health Board director of nursing, Sandy Blake, said it made several recommendations, all of which were implemented.
The death occurred in 2004, when Whanganui's maternity services were provided from a very old building. It has since been demolished and replaced with a new facility with state-of-the-art birthing rooms and emergency call systems.
Independent midwives still use the facility, under the same access agreement.
They are not required to have another midwife with them at births, but Ms Blake said that was accepted best practice, and was supported and encouraged by the board.
All newborn babies are observed for the first 30 minutes of life by a health professional, and desks have been provided in birthing rooms so that midwives can write up their notes there.
There are telephones in the birthing rooms and resuscitation room, and a new emergency bell that sounds through the entire acute services block.
The board supports Coroner Evans' findings on the case, Ms Blake said, and acknowledges how distressing the investigation and findings must be for the family. It extended its deepest sympathy.
A Justice Ministry spokesman was unable to say why it took so long for a coroner's inquiry to be held, and why it was held by a Wellington coroner. He said Coroner Evans and the Chief Coroner were both on leave at present.
The answer may have something to do with leaving time for police to determine whether to prosecute.
The death of Whanganui Coroner Colin Riddett is also a factor, and after that the change to delivering coronial services from just nine regions in New Zealand.
Wanganui's service is now delivered from Palmerston North, where the coroners are Carla na Nagara and Tim Scott.