Pippa Griffiths died on April 27, 2016, from a group b strep infection – the most common cause of meningitis in newborns.
At an inquest held at Shirehall in Shrewsbury, Shropshire coroner John Ellery was told that Shrewsbury and Telford Hospitals NHS Trust admitted failings in the information provided to Pippa's mother, Kayleigh, which could have prevented her newborn daughter's death.
The trust also accepted that had questions been asked when Mrs Griffiths raised concerns to a midwife over the phone then Pippa would have been taken to hospital, in all likelihood leading to her receiving treatment and surviving.
The inquest was told that Mrs Griffiths had given birth at home in Myddle, between Shrewsbury and Wem, with two midwives but was not provided with a leaflet following Pippa's delivery that would have advised her on potential warning signs.
The hearing was told that the leaflet, which should have been provided by the midwives, would have given Mrs Griffiths information to register concerns that midwives would have been acted on.
Speaking after the inquest Mrs Griffiths said that having subsequently seen the leaflet she was "in no doubt" that it would have led to her raising concerns which would have saved her daughter's life.
Despite not having seen the leaflet Mrs Griffiths had still become concerned because Pippa was not feeding and was "mucusy". She had also appeared purple and "mottled".
She had spoken with midwives over the phone to raise concerns about her daughter's condition but there had been no visit to her home as expected by the trust within 24 hours of a home birth.
Pippa and her mother were flown to Princess Royal Hospital after a 999 call when she was found with difficulty breathing. She was confirmed dead at the hospital at around 4pm.
Giving evidence Sarah Jamieson, head of midwifery at SATH, said a script has been created to ensure that the correct questions are asked of mothers who raise concerns over the telephone.
She confirmed that if such a "complete systematic inquiry" had taken place then Pippa would have been admitted for treatment.
It also emerged during the hearing that notes of another call from Mrs Griffiths to Royal Shrewsbury Hospital's midwife led unit, had not been recorded until 16 hours after the call.
Mrs Jamieson said this had also been addressed but added: "I would expect a record of that discussion should have been recorded."
Mrs Jamieson told the inquest that there is an "ongoing management investigation" relating to Pippa's death, which is part of the trust's disciplinary process.
Mr Ellery recorded a narrative conclusion and said that Pippa's death was preventable.
Concluding he said: "Pippa's death was preventable had post delivery literature been given, had a complete systematic inquiry about post natal health taken place then it is more likely than not that signs of poor post natal health would have been elicited."
Mr Ellery said those signs would have led to care which would have prevented Pippa's death.
Mrs Griffiths and her husband Colin said they hoped the case would act as a legacy to Pippa, and would raise awareness to ensure no other parent is faced with the same tragedy.
Speaking after the conclusion Sarah Jamieson, head of midwifery at The Shrewsbury and Telford Hospital NHS Trust, apologised to Pippa's parents and said that lessons had been learned.
She said: “We are truly sorry that we were unable to provide the appropriate care that would have prevented Pippa’s death. We have apologised to Pippa’s parents and we repeat that apology again today.
“We know that nothing can make up for the loss of a child. However, we have carried out specific actions to address the issues this tragic case has highlighted to ensure we learn from these devastating events.”
What is Group B Streptococcus?
Group B Streptococcus is a bacteria present in the gut of about 20 per cent of men and women.
One in 2,000 babies contract an infection when the bacteria is passed onto them during birth.
Group B Strep can cause meningitis, septicaemia and pneumonia in newborn babies.
One baby a week dies and one baby a fortnight suffers long-term disabilities.
Jane Plumb from Sussex who founded charity Group B Strep Support with her husband Robert when they lost Theo at just 17 hours old due to a GBS infection.
France Germany and Canada are among countries who test for it as standard procedure.
In this country, any mother wanting advice or help to protect them normally need to make the first move.,
Dr Alison Bedford Russell, neonatal consultant at Birmingham Women’s NHS Foundation Trust, said women here can seek a test by talking to their midwife or pay about £35 to be screened privately.
She said mothers should have the choice of screening and antibiotics on the NHS.
“I really lament the fact that we see babies with severe infections that can have severely compromising outcomes for an illness that’s preventable,” she said.
Dr Anne Mackie, director of programmes for the UK National Screening Committee said the number of women that would be offered antibiotics if they tested positive would be “very high”.
She said there were concerns that a nationwide screening programme could “expose the mother and baby to unnecessary antibiotic use”.