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The Health and Disability Commissioner's report, released this afternoon, has come more than four years after baby Adam Barlow died in October 2009 and his mother Linda Barlow was left with debilitating injuries following a horrific labour that former Hamilton midwife Jennifer Rowan was in charge of.
It follows an investigation into the case by Health and Disability Commissioner Anthony Hill after Mrs Barlow and her husband Robert laid a complaint last year.
It has referred the case to the Director of Proceedings to determine whether any proceedings should be taken against Ms Rowan, who still has a current practising certificate with no conditions under the name Jen Campbell.
The report is also critical of the Waikato District Health Board obstetrician who oversaw the end of Mrs Barlow's labour at Waikato Hospital, saying they did not adequately assess Mrs Barlow.
It goes on to say that Mrs Barlow also received poor midwifery care from hospital midwives.
Adam was declared stillborn, but a coronial inquest was ordered after his parents read medical notes indicating their son had shown signs of life.
The Barlows blamed the inexperience of Ms Rowan, who had been a midwife for seven months at the time, as a major factor in their son's death.
Coroner Gordon Matenga said after the inquest in May 2012 that baby Adam's death by intrapartum asphyxia was brought on by several factors including Ms Rowan's failure to recognise that Mrs Barlow's labour was not normal.
He also found Ms Rowan did not convey any urgency, verbally or in writing to Waikato Hospital staff when they arrived via ambulance.
Mrs Barlow suffered a ruptured uterus and stopped breathing after being given an epidural.
She had an emergency caesarean but was bleeding profusely internally and had to have an emergency hysterectomy.
She suffered a heart attack on the operating table and needed cardiac massage for six minutes before being taken to intensive care on life support, not knowing that her little boy had died.
As a result of what happened Mrs Barlow was unable to have any more children herself but the Barlows had a baby boy almost two years ago through in vitro fertilisation and using a surrogate mother.
In a statement, the Barlows said: "Our family, including our little boy Adam, experienced and suffered through a frightening and torturous labour on October 25, 2009 that left Linda on life support and resulted in the preventable and devastating death of our much loved son.
"Since that harrowing experience we have continued to seek answers for Adam's untimely death, and Linda's injuries, in the hope of preventing similar outcomes for future parents and their babies."
They thanked the Health & Disability Commissioner for his investigation and findings, which they said were fair and the outcomes proportionate to the areas of the maternity system that let them down the most.
"We suffered a shocking lack of basic midwifery care with a lack of humanity on October 25, 2009 by a self employed new graduate LMC midwife in the community."
They challenged Health Minister Tony Ryall and all health professionals - particularly the midwifery sector - to accept the findings, to learn from them and put into place a far safer environment for all future mothers, fathers, babies and midwives in New Zealand.