A Highland couple experiencing concerns with their unborn baby were told to drive three hours to the nearest hospital, instead of being given an ambulance.
The tot later suffered brain damage and had to be resuscitated by medics.
NHS Highland bosses have been ordered to change their ways of working and apologise by the Scottish Public Services Ombudsman.
The couple, referred to only as C and their pregnant partner A in the watchdog’s report, first attended a local hospital as A was experiencing “abdominal discomfort”.
After an examination, they were advised to drive to Raigmore Hospital in Inverness – three hours away.
When they arrived, A was told she might be going into labour.
It was later determined she wasn’t, but was kept in hospital overnight and discharged the next day.
A week later, the couple arrived back at the local clinic where it was suspected A’s waters had broken.
They were again told to drive to Raigmore and assured that an ambulance wouldn’t be needed.
Medics there confirmed their suspicions and, in the early hours of the following morning, A went into labour and had a C-section.
They had to resuscitate her newborn child following the procedure.
Baby had ‘most severe’ level of injury
Three days later, a scan revealed the baby had suffered some brain damage, which could lead to long-term problems with muscle control, thinking and learning.
Repeated scans in the following weeks found cysts had started forming in the youngster’s brain, categorised as the most severe level of illness.
The SPSO has ruled that, during both admissions, NHS Highland “failed to provide reasonable care” to A and B.
It has told the board to apologise for failing to carry out adequate assessments or making safe transport arrangements.
NHS Highland has also been told to develop better plans for rural and remote women at risk, or whose waters have broken early.
A spokeswoman for the health board confirmed that chief executive Pam Dudek has written to the family to apologise.
She added: “We have fully accepted the recommendations in the report from the SPSO and actions are being implemented.”