Milton Keynes Hospital staff missed baby's condition
A midwife's heart monitoring during delivery "failed to recognise" a baby's "deteriorating" condition, a coroner has ruled.
Lorna Howell, 20, gave birth to her brain-damaged son Alex Broughton on a ward at Milton Keynes General Hospital in December 2009, but he later died.
Coroner Tom Osborne said evidence showed the boy's decline should have been seen in a changing heart rate.
Medics had "lost an opportunity" to speed up the delivery, he said.
Mr Osborne, who delivered a narrative verdict at the end of the inquest, said there had been conflicting evidence about how midwife Clare Davis had monitored Alex's heart rate.
He also said an Oxford medical student observing the birth had given "surprising and unhelpful" evidence to the inquest into Alex's death in Milton Keynes, Buckinghamshire.
It is the second time in eight months that the hospital's maternity unit has been in the spotlight.
In December 2009, Mr Osborne complained that midwife shortages at the hospital were "nothing short of scandalous" after hearing how new-born Ebony McCall had died on an over-stretched maternity ward in May 2009.
He said, following an inquest in Milton Keynes, that hospital "systems failures" had contributed to Ebony's death.
Alex's grandfather, Alan Broughton, said it appeared that "serious problems continued" in the hospital maternity unit.
Mr Osborne told the inquest: "The monitoring of his fetal heart rate during delivery failed to recognise his deteriorating condition prior to his birth."
He added that this "failed to trigger any concern for his well being that resulted in a lost opportunity to expedite his delivery and render further medical treatment".
The inquest also heard how the couple received a hospital "birth congratulations" letter on the day Alex died.
The hospital said the death of Alex was very different from the death of Ebony McCall.
"His (Alex's) mother was given one-to-one care buy a qualified midwife and appropriate procedures were followed," said the hospital in a statement.
"We have made a number of improvements to our maternity services.
"We have also recruited a number of new midwives, despite a national shortage."