Dr. Dmitry Shelchkov, an anesthesiologist at a public hospital in a predominantly Black neighborhood in Brooklyn, would later say that his job was “straightforward” with “not a lot required.”

But when it came time to give an epidural to Sha-Asia Semple, a pregnant 26-year-old woman in labor, at Woodhull Medical Center on July 3, 2020, Dr. Shelchkov botched the routine procedure. The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches, a state medical review board later found.

Then Dr. Shelchkov administered a full dose of anesthesia, without waiting to see how Ms. Semple responded to a small test dose, according to the state board. The anesthesia landed in her cerebrospinal fluid and circulated around her central nervous system.

“I can’t breathe,” Ms. Semple said as her breathing grew labored, before stopping altogether. Another doctor rushed in to help.