Six years after the avoidable death of baby Kate Stanton-Davies, born at Ludlow's midwife-led unit in March 2009, a review of the case has said a previous investigation into the case was "not fit for purpose" and called for it to be done again.
The report comes after years of parents Richard Stanton and Rhiannon Davies calling for an inquiry. A jury inquest in 2012 and an investigation by the Parliamentary Health Service Ombudsman in 2013 both concluded Kate's death was avoidable and the result of serious failings in care.
Shrewsbury and Telford Hospitals NHS Trust (SaTH) apologised to the the couple in January but has now agreed to fully re-investigate the case and its handling of complaints.
Kate Stanton-Davies was born with anaemia at Ludlow Hospital before being transferred to Birmingham's Heartlands Hospital but died six hours after she was born.
The 2012 inquest found that Kate would have survived if she had been born elsewhere and that the original classification of the pregnancy as low-risk was a contributory factor in her death.
The review by Debbie Graham for NHS England said midwives repeatedly failed to follow guidelines and best practice.
It concluded that the investigation in 2009 by the local supervisor of midwives, Angela Hughes, who also works for SaTH, was "poor", included "multiple inaccuracies" and did not properly investigate key lines of enquiry.
The review also suggested Ms Hughes had breached her own professional code of conduct by using "offensive" language at one point in her report to describe baby Kate as "it".
In its conclusions, the report for NHS England drew parallels with the recent high-profile inquiry into the death of 11 babies and a mother at Furness hospital in Cumbria.
It said: "The reviewer identified significant factors in the case common with those identified in the Morecambe Bay investigation including poor quality records, retrospective completion of clinical notes and conflicting accounts of events.
"The finding of this review is that the supervisory investigation into the case of Kate Stanton-Davies and her mother Rhiannon Davies is not fit for purpose."
Sarah Bloomfield, SaTH's director of nursing and quality, said: "We recognise that the care provided for Ms Davies and her daughter in 2009 failed to meet the high standards we set for every one of our patients.
"As director of nursing and quality my first and foremost priority is the care and safety of our patients, which is why we have commissioned our own independent review into both the care and treatment provided to Ms Davies and her daughter and the trust's subsequent handling of the couple's concerns and the governance around the management of the incident itself.
"Furthermore, we recognise that we also fell short in the trust's complaint handling process, and we are truly sorry for the added pain and distress this has caused.
"I have personally discussed this review with Mr Stanton and Ms Davies and they have kindly agreed to work with us to help ensure it examines all of their concerns."