Two midwives face questions over death of Shropshire baby
Two midwives should face action over the death of a baby born at Ludlow Hospital, a report says.
It says there are "serious concerns" over their fitness to practice after an investigation into events surrounding the death of baby Kate Stanton-Davies in 2009.
The recommendation follows an independent NHS investigation.
The report, which was commissioned in September, follows a ruling by NHS England that a previous investigation was "not fit for purpose".
It has recommended two of the four midwives involved should be referred to the Nursing and Midwifery Council.
A third nurse should be put on a period of supervised practice, the report says.
The clinical notes for baby Kate were changed after her death and the original records did not match an electronic copy, the report says. There was "no explanation" for the discrepancy.
The midwife who altered the notes claims she was told to do so by a supervisor, who was also the one responsible for originally investigating the death in 2009.
Parents Richard Stanton and Rhiannon Davies have spent many years calling for an inquiry.
Kate was born with anaemia at Ludlow Hospital before being transferred to Birmingham's Heartlands Hospital. She died six hours after she was born.
A jury inquest in 2012 and an investigation by the Parliamentary Health Service Ombudsman in 2014 both concluded Kate's death was avoidable and the result of serious failings in care.
Kate's mother Rhiannon Davies said: "The biggest regret of my life is that I trusted the trust, its midwives and its managers. I trusted that they had policies in place, training, staffing and safe practices."
She said the findings from the new investigation meant other similar cases should be re-investigated.
Shrewsbury and Telford Hospital NHS Trust said lessons had been learned.
