Two midwives failed in their care of newborn baby Joshua Titcombe, denying him the opportunity to be seen by a doctor before he died, it has been ruled.
Neither Lindsey Biggs nor Holly Parkinson referred matters to a paediatrician as they should have done when they found Joshua had a low temperature while he was being cared for at Furness General Hospital in Cumbria.
He was born at the hospital on October 27 2008 but died nine days later after suffering pneumococcal septicaemia and a lung haemorrhage.
The case at a hearing of the Nursing and Midwifery Council (NMC) in London was told their failures had caused baby Joshua, referred to as baby A, to lose a significant chance of survival.
Panel chairman Stuart Gray said both women had been "guarded" in giving their evidence and at times appeared to have "distanced" and "detached" themselves from the events of the day.
He told Ms Biggs: "You were the midwife responsible for the care of baby A shortly before his collapse."
But rather than going to a doctor, he said: "You took matters into your own hands and placed baby A into a warming cot."
Ms Biggs, the panel concluded, failed to make sure three-hourly observations were conducted on the newborn, failed to get a paediatrician when she saw he had a low temperature and failed to properly record notes on his mother Hoa, who was also being cared for at the hospital.
Ms Parkinson also failed to get a doctor when she recorded Joshua's low temperature. She had already admitted failing to document the paediatrician's advice that observations should be carried out.
Their failures "denied baby A any opportunity to be seen, assessed and treated by a paediatrician", Mr Gray said.
He added: "This was the significant chance for baby A that was lost."
Joshua's mother and her husband James, from Dalton-in-Furness, have both claimed they repeatedly told hospital staff she felt unwell the day before giving birth and was concerned about catching an infection from her young daughter who had been sent home ill from nursery.
An inquest in 2011 heard midwives repeatedly missed chances to spot and treat a serious infection which led to Joshua's death.
Reacting to the outcome of the hearing on Tuesday, Joshua's father James said: "Obviously I'm deeply sad.
"To see these words on paper has a huge meaning for us. It's about not having a little boy with us who would be seven years old.
"But it is a relief that the truth has finally been proven.
"We have faced years and years of denial and have not felt that any of the midwives involved have ever accepted any responsibility for what happened.
"If we had been told the truth to start with then the last seven years would have been much easier for us, we wouldn't have wanted any action or blame against the midwives.
"It is the denial that has been so hurtful.
"It's a huge relief to our family that the truth has finally been established."