Ruth Toyoshima was so terrified of returning to Hutt Hospital following the death of her baby Ellie, she went to another hospital to have her second child.

Ellie died in In July 2016 , six days after she was born after receiving brain damage caused by oxygen deprivation at birth.

Deputy Health and Disability Commissioner Rose Wall on Tuesday released two reports highlighting "systemic failures" and a "pattern of poor care" at the Hutt Valley District Health Board following complaints about the state of its maternity services.

The release addressed Ellie's death and an incident in which another baby was left with a brain injury.

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Toyoshima said the report into her daughter's death was damning and she was pleased a spotlight was being put on the Hutt's maternity services.

She described the DHB's treatment of her and her husband, Kazu, as appalling with the only contact following Ellie's death being a meeting in October 2016 to inform them of operating procedure changes.

"They were terrible to us and we didn't have any answers until the HDC chased them up for this investigation. No apologies and no follow up."

She was so wary of the Hutt DHB the couple, who live in Upper Hutt, opted to have their son, Lyoma, at Wellington Hospital in 2017.

SUPPLIED/TOYOSHIMA FAMILY Kazu and Ruth Toyoshima's daughter, Ellie, lived just six days at Hutt Hospital. She suffered brain damage caused by oxygen deprivation during birth.

An external review of the Hutt's Maternity services had since been completed. Most recently the maternity service came under scrutiny when midwives spoke out about the pressure caused by under-staffing at an emotionally charged meeting in November last year.

"The review identified several areas of risk that threatened the safety of the service, including a severe staff shortage," Wall's report said.

She was critical of the systems and processes, noting many failures.

In the case of the Toyoshimas, Ellie was in an occipital posterior position - the baby's head was faced towards the mother's spine. The position can cause a slow and obstructed labour.

The baby required delivery by emergency Caesarean section after her heart rate deteriorated.

HEALTH AND DISABILITY COMMISSIO The country's Deputy Health and Disability Commissioner Rose Wall says the Hutt Valley DHB failed to adequately care for two women during labour.

Ellie suffered severe brain damage due to oxygen deprivation and died six days later.

"The DHB must ensure that it has in place appropriate staffing levels, policies that provide sufficient guidance, and equipment in good working order, so that staff are supported adequately to provide safe care," Wall said.

She also found the obstetrician in breach of the code, criticising her for not adopting a more cautious approach.

SUPPLIED/TOYOSHIMA FAMILY Ruth Toyoshima said she and her husband had been treated poorly by the Hutt Valley DHB following the death of their daughter, Ellie.

In the second case, the baby was born with a brain injury during an early induction in which the woman experienced excessively frequent contractions.

As labour progressed the fetal heart rate was not recognised as significantly abnormal resulting in the child's brian injury, the report said.

Wall was critical of systemic failures at the DHB, including a lack of clarity in policies and procedures.

She was also critical of several aspects of the care provided by an obstetrician involved and recommended the Medical Council of New Zealand consider undertaking a further competence review.

SUPPLIED Failures at the Hutt Valley DHB put mothers and their babies at risk, deputy commissioner says.

Both reports found the Hutt Valley DHB in breach of the Code of Health and Disability Services Consumers' Rights.

Hutt Valley DHB chief medical officer Dr Sisira Jayathissa said the DHB accepted the findings.

No harm to a patient in the organisation's care was acceptable and a range of improvements had been made.

The health board was aiming to have the further recommendations from the Health and Disability Commissioner implemented by the end of the year.

Associate health minister Julie Anne Genter said in a statement she ​ understood there had been long standing issues within the maternity services unit.

She had asked the health board to take note of the recommendations outlined in an independent review of the service which was completed in November 2018.

Hutt South MP National's Chris Bishop said he'd spoken with health board' chief executive Fionnagh Dougan late last year and had been assured more resources would be allocated to midwives.

"It's critical for Hutt families to have access well funded maternity services."

Hutt South based Labour MP Ginny Andersen said it was clear from November's meeting not all the recommendations from the external review had been followed.

She would continue to work with midwives and the DHB to ensure the Hutt had capable maternity services.

Chief Executive of the College of Midwives, Alison Eddy said under-funding of maternity units over a number of years had contributed to "tragic outcomes" like those in the report.