An obstetrician has been found guilty of professional misconduct after a baby died following a 20-minute delay in deciding on an emergency caesarean.
The baby was delivered stillborn in 2010, dying from a lack of oxygen.
The Health Practitioners Disciplinary Tribunal found the obstetrician - whose name was suppressed - made basic errors.
It also found the hospital midwives involved should have called the doctor sooner, when it became obvious the mother was in distress.
The doctor told the tribunal he had a heavy workload due to staff shortages and a lack of sleep might have contributed to his failure to make the right decision.
But the tribunal was told the actions of midwifery staff, or the doctor's workload and tiredness, did not excuse his lack of decision-making.