Baby's death could have been avoided after errors at Telford's Princess Royal Hospital, coroner rules

Ivy Morris died after collapsing at home during a feed, just months after being born with severe perinatal hypoxic ischaemic brain damage.

Mr John Ellery, coroner for Shropshire, ruled that because of ineffective monitoring of Ivy's heartbeat during her birth and a delayed second stage of labour which caused her life limiting needs, the baby from Oswestry was vulnerable to bronchopneumonia.

Hospital bosses today apologised for the errors made during Ivy's birth.

Ivy's family said they hoped that changes in protocols and guidance would be made that would prevent anyone else having to go through the heartbreak of losing a child.

An inquest on October 12 heard that Ivy was born at the Princess Royal Hospital in Telford with life-changing needs after suffering from hypoxia – a lack of oxygen.

The machines which were supposed to be monitoring her heartbeat during labour were in fact picking up on the heart rate of her mother, the inquest heard. There was also a delay in the second stage of labour.

This meant it would not be possible to identify an abnormal heart rate in Ivy during her birth.

Andrew Tapp, care group medical director for women and children's services at Shrewsbury and Telford Hospital NHS Trust, said: "I would like to express my sadness at the death of Ivy Morris and would like to give my sincere apologies to Mr and Mrs Morris and their family for their loss.

"We have carried out a number of investigations into Ivy's sad death and we have found that there were opportunities when the staff could have been alerted to problems with monitoring during the late stages of labour and managed care differently.

"We addressed matters immediately with members of the team. We have sent clear messages to staff to watch out for the possibility of monitoring errors.

"These improvements have continued with clearer instructions on monitoring to maternity staff. We have also provided specific training and carry out audit reviews of our staff's understanding and knowledge of this important subject. This has been supported by the purchase of a training package for both doctors and midwives.

"Although the possibility of error is recognised by manufacturers and is highlighted to users of this equipment we must be ever vigilant."

Ivy had a prolonged stay in hospital following her birth and on going home she required food through a nasogastric tube. When she was seen to become unresponsive on May 3 her father called an ambulance and started resuscitation.

She was rushed to Royal Shrewsbury Hospital but died.

Ivy's mother Tamsin said: "Our lives have been changed forever and no outcome from the inquest will bring Ivy back to us.

"We cherish every day we had with her but it was not long enough. Not only did we lose our baby girl but our three-year-old daughter Edie lost her little sister."

"We would like to thank our family and friends and the charity Hope House which continues to support us at this difficult time. We would appreciate the time and privacy to grieve and hope to look forward from today."