Hutt Valley DHB has apologised for a series of issues that led to a premature twin suffering brain damage in birth.
At one point, doctors trying to save the baby's life realised the oxygen tank wasn't turned on.
A Health and Disability Commission report into the birth has been released today, finding a radiologist and the DHB had failed in the obstetric and pediatric care of a woman and her identical twins.
During an ultrasound scan when the woman was seven months pregnant, a radiologist didn't note any indication of twin-to-twin transfusion syndrome - a condition where twins grow at different rates due to sharing unequal amounts of the placenta's blood supply.
Three days later, a different obstetrician saw "obvious" evidence of the condition and recommended an urgent cesarean section.
But the surgery theatre wasn't prepared for a twin birth, with only one delivery unit.
The first baby was born pale, floppy and without a heartbeat, needing immediate resuscitation.
It took three attempts to intubate her, before it was discovered the oxygen tank wasn't turned on.
The baby suffered brain damage during the birth, developing right hemiplegia - paralysis of the right side. Her mother wasn't told until a week later.
"At this meeting they explained [Twin 1’s] injury however they did not mention the issues in theatre, instead stating brain bleeds were common in prem[ature] babies," she told the HDC.
The second baby was born in "good condition".
The Health and Disability Commission says there were multiple failures during the birth, including a too-small intubation tube as well as the issues with the oxygen.
Hutt Valley DHB has apologised for the issues, saying it "unreservedly accepts the Health and Disability Commissioner’s finding that we breached the Code of Health and Disability Services Consumers’ Rights, by failing to provide services of an appropriate standard".
"We would like to apologise to the family once again and convey our sincerest regret," director of provider services Joy Farley told 1 NEWS in a statement today.
"No harm to a patient in our care is acceptable and in this instance, we acknowledge that we failed our patient and family."
Meanwhile, the initial radiologist now "avoids reporting on twin pregnancies", saying he has "reflected on this incident on an almost daily basis" and how he could have done better.
Hutt Valley DHB says it's made numerous changes since the case, including upgrading its equipment, bringing in mandatory newborn life support training courses, and creating new positions for midwives to be on-call for all caesarean sections.
"As we move into the future, the DHB remains focused and committed to monitoring and reviewing recommendations and outcomes," Farley says.
The woman was in her 20s at the time of the birth.
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