The death of a newborn baby could have been avoided if there had not been a series of delays in transferring his mother to hospital, a coroner had said.
Rafe Angelo died shortly after arriving at Queen Alexandra Hospital in Portsmouth on September 23, 2014.
An inquest at Portsmouth Coroner’s Court heard his mother Kelly Angelo had been transferred shortly before the birth from the midwife-led Blake Birthing Centre in Gosport.
But a new midwife at the centre took several hours to arrange for an ambulance to be dispatched and did not know how to make the emergency call.
In a statement after the hearing South Central Ambulance Service said the midwife was not aware of the process for ‘time-critical’ calls, and the call was categorised as requiring a response within 30 minutes.
The ambulance crew took a short toilet break on their way to the centre, and on arrival were made to wait 10 minutes while Ms Angelo was made ready for transportation.
A hearing last year heard after being put in a birthing pool to help with pain relief, meconium - a baby’s first faeces - began leaking out of Ms Angelo, prompting staff to call for an ambulance.
Once at hospital she was taken to the wrong door and there were no hospital staff around to help her.
Ms Angelo gave birth to Rafe but he died of oxygen starvation 37 minutes later.
Resuming the inquest yesterday, the coroner gave a narrative verdict and said she would write to the organisations involved.
A spokesperson from Portsmouth Hospitals NHS Trust, which manages the hospital, said: ‘The trust would like to extend its deepest sympathy to the family at this difficult time.
‘We hope the evidence at the inquest answered the family’s questions with regards to Rafe’s care.
It added that the trust had made ‘a number of changes’ following the death.
Mark Ainsworth, director of operations at SCAS, said a updated version of the Time-Critical Transfer Process for requesting an ambulance had been sent out to senior midwife managers.
In a statement the family’s solictor Victoria Hydon said: ‘The family of Rafe wish to express thanks to the coroner for her thorough investigation and have stated their wish to ensure where possible such a tragic event does not happen again.
‘It has been a privilege to represent Kelly and her family who have acted in a very dignified manner through a gruelling but thorough inquest process.’