A doctor "did nothing" to prevent the death of a baby who was starved of oxygen during labour, an inquest heard.
Elliot Williams was pronounced dead at St Mary's Hospital, Isle of Wight, on 22 December 2015.
The inquest heard midwife Diane Weedon and registrar Dr Tin Tin Htwe failed to recognise signs of foetal distress.
Recording a narrative verdict, coroner Caroline Sumeray said "systemic gross neglect" had led to the baby's "totally avoidable" death.
The inquest, in Newport, was told how an electronic foetal heart monitor showed Elliot's health was in serious decline two hours before his birth.
Ms Sumeray said Mrs Weedon did not monitor the baby's heart adequately or get assistance from other midwives and summoned Dr Htwe "far too late".
"You [Dr Htwe] stood at the back of the room... faffing around. It was like a car crash in slow motion."
The registrar said: "My fault was I did not do an instrument delivery. I thought it was very imminent to deliver."
Mrs Weedon said: "It's an awful mistake. I lie awake at night."
Elliot was born "in a moribund state", 48 minutes after the doctor arrived.
The court heard it was "highly probable" Elliot would have been born healthy if he had been delivered at the earliest opportunity.
He died 10 hours later, when his parents, Nicholas Williams and Chelsea Mouland, from East Cowes, agreed medical care should be withdrawn.
Ms Sumeray said both Mrs Weedon and Dr Htwe should be investigated by their professional bodies.
The Isle of Wight NHS Trust's chief nurse, Dr Barbara Stuttle, said: "There are problems. The organisation has clearly failed them.
"Because of the small number of births on the island, we have to be ready for anything and I have to work out how to do that."
The inquest was told the trust had implemented a number of recommendations after an independent review.