A baby who died hours after her birth may have survived if her parents' repeated requests for a caesarean delivery were listened to.
A coroner also found a plethora of issues at the hospital where the botched birth took place, including the failure to follow policies and inability to access patient records.
But the coroner made no recommendations, as local health authorities have already addressed all her concerns.
Charlotte Harding was born in Palmerston North Hospital, New Zealand in the early hours of August 11, 2015. She died 10 hours later in the arms of her parents Kris and Stacey Harding.
In findings released this week, Coroner Morag McDowell outlined the mistakes made in Charlotte's care.
There were issues from a month before Charlotte's birth until her botched delivery at Palmerston North Hospital.
McDowell found Charlotte's parents should have been referred to an obstetrician for discussions about caesarean delivery due to her mother Stacey Harding having previously difficult deliveries.
The Hardings arrived at hospital at 9.20am on August 10, 2015, after Stacey Harding noticed a lack of movement in the womb at 6.50pm and was told by her midwife to monitor movements for an hour.
A junior doctor, who has name suppression, called for an emergency caesarean after seeing irregularities on a fetal monitor at 11.26pm.
But that decision was over-ruled by the on-call senior doctor, who also has name suppression, when he arrived at hospital and reviewed the monitor readings just before midnight.
The senior doctor wanted to try a natural birth instead, which the coroner said was an appropriate decision
A caesarean was not performed until 4.45am, when attempts to induce labour failed and Charlotte's heart rate dropped.
Inducement, which began at 3.06am, should never have been tried, with caesarean performed instead when the delivery reached that point, McDowell said.
The caesarean should have been done at 2am, but the senior doctor failed to review the monitor records correctly then.
"This is not a finding made in hindsight," McDowell said.
"The post mortem findings show that Charlotte was compromised prior to her delivery."
While Charlotte had suffered a brain injury as many as three days before delivery, she could have lived if the caesarean was performed two hours earlier, McDowell said.
Unclear communication from the senior doctor meant the junior doctor was confused with readings from the fetal monitor, while midwives did not follow monitoring policy and did not alert doctors when she saw worrying signs on the monitor.
A midwife also failed to follow inducement policy, while another should have spoken up about Stacey Harding's preference for caesarean and difficult previous deliveries when the senior doctor could not find the information, McDowell said.
Stacey Harding's previous medical notes were hard to source because the hospital was transferring to digital note-taking technology.
HOSPITAL ACCEPTS FINDINGS, MAKES CHANGES AFTER 'TRAGEDY'
Reviews were carried out before Thursday's findings, which led to changes at the hospital before the coronial process ended.
MidCentral's acting chief medical officer Dr Jeff Brown said McDowell's findings were accepted in full.
Staff had been given significant training on clear communication and fetal monitor reading, while policies governing maternity services were simplified.
There was also an obstetrician fully dedicated to the delivery suite, and an associate charge midwife position created to keep fresh eyes on monitors and speak up if they saw anything amiss, Brown said.
While the new digital record system was in place, the Ministry of Health has proposed shifting to a new system which would enable easy access to records between all district health boards.
Brown said MidCentral was working with the ministry to ensure it learned from all the mistakes made in Palmerston North.
"We are not being silent on our difficulties.
"People around the country will have improved care, not just the next baby born in MidCentral."
The maternity suite was a very different place four years on from Charlotte's death, he said.
"We all wish [Charlotte's death] never happened.
"It is a tragedy – we have to accept that, and we do."
Individuals involved and those overseeing maternity care had reflected on how they could create permanent change to ensure the same thing never happened again, he said.
"There is a much different culture in place now, which is a complement to all of those things that have been put in place."
Charlotte's father Kris Harding has not replied to messages, but previously told Stuff he was happy changes had been made to maternity services.
"I think it's a turning point, I think it's a positive thing. This is what me and Stacey were hoping for.
"We know nothing is going to bring our daughter back, but it will help in the future."
This article was first published on Stuff NZ.