A senior doctor has apologised and asked forgiveness from parents whose daughter died after a complicated birth.
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An expert witness has told the coroner the baby Charlotte Harding would have survived - but may still have had brain damage - if an emergency C section had been performed earlier.
It comes after the consulting obstetrician apologised to Charlotte Harding's parents, and admitted his misreading of a heart-rate monitor contributed to the delayed call for a c-section, meaning she was born oxygen-starved and in a poor condition.
Expert witness Dr Astrid Budden said the call to cut the baby out should have been made earlier.
"An earlier Caesarean section would've likely saved the life of the baby but would have not guaranteed her to be neurologically intact."
The consulting obstetrician, whose name is suppressed, apologised to them and asked for forgiveness.
He said he cancelled a junior registrar's decision to perform a crash Caesarean shortly after the family arrived at the hospital. He said he chose to proceed with a vaginal birth quickly without access to the patient's files because the new electronic record-keeping system was not working properly.
He signed a printout of the heart rate readings, or trace, without unfurling all of the pages to see whether there had been any changes while he was out of the room - which he identified as a root cause problem.
"If you mean ... the baby being delivered in as sick a state as Charlotte was, it would have to be my misreading of the trace ... my failure to recognise ... deterioration in the trace," he said.
He said he would have appreciated the midwife monitoring the mother and baby, to have alerted him to the baby's rapid heart rate.
Dr Budden said those problems reading the trace led to the delay in cutting the baby out.
"I don't think he was not diligent or caring and I think he kept coming back to the trace and he kept coming back to the room. Unfortunately, he made an error that night," she said.
The coroner also heard of several communication issues - between the family, doctors, midwives, and the dysfunctional electronic notes system - meaning relevant information wasn't passed on to those who needed it.
A post-mortem report showed an extensive brain injury as a result of a low-oxygen environment, occured at least three days before Charlotte died.
Pathologist Dr Jane Zuccollo said she also found significant problems with the placenta and the umbilical cord which was knotted and later compressed.
However, she could not identify an exact cause of death.
It's also thought that tests on the mother may have led to a loss of fluid supporting the baby, meaning she was resting on the umbilical cord, impeding the blood flow.
Coroner Morag McDowell acknowledged the family's stoicism.
"I, once again, can acknowledge how distressing it must be to sit through a process which has you relieving one of the most traumatic and painful days of your lives."
The coroner will now consider the evidence and present her findings at a later date.
