A mother has revealed her distress at being told her newborn baby was stillborn - when she was convinced the little girl had been born alive.
In fact, Ava Mae Charlton was born by emergency caesarean section but she struggled to breathe and died after only 32 minutes.
However, hospital officials tried to claim the baby was stillborn and so her death did not need to be investigated.
Mum Emma Charlton said: "People questioned my sanity and it was infuriating because I knew my baby had been alive. I was grief-stricken and vulnerable and you just accept what health professionals tell you.
"But when they handed me that stillborn certificate, I knew something wasn't right. Then a meeting with our consultant opened up a whole can of worms and highlighted a number of errors that had been made."
It ignited the start of a legal battle that took two years for teacher Emma, 31, and husband Terry. But they have eventually been proved right after Milton Keynes Hospital finally admitted that Ava had not been stillborn.
An inquest ruled that medics should have carried out an emergency caesarean more than an hour before they did, when the baby became distressed during the birth.
Emma said: "The inquest at least gave us some answers to our questions about how the pregnancy was managed and the death of our baby daughter Ava Mae.
"We're still bitter about the fact that it took more than two years for the Trust to concede that Ava Mae was not 'stillborn' as they originally claimed, and as we questioned immediately when we were handed the certificate."
The Charltons' solicitor, Phil Barnes of Shoosmiths, said: "The medical records clearly showed there were signs of life after birth and this was Emma and Terry's driving motive in pushing for an inquest to be heard."
Delivering a narrative verdict, Coroner Tom Osborne said: "Ava Mae Charlton was born by emergency caesarean section at 01.53 on 16th September 2009 and died at 02.25 the same day at Milton Keynes Hospital.
"Her mother had been admitted to the hospital on the 14th September 2009 with pre-eclampsia. She underwent induction of labour prior to the emergency caesarean section.
"Ava became distressed at 00.25 on the 16 September and there was a failure to recognise the seriousness of her condition and a delay in carrying out the emergency caesarean section that resulted in a lost opportunity to render to her further medical attention."
Mr Osborne said that as a direct consequence of Ava's death he now requires all stillbirths and neonatal deaths in his jurisdiction to be reported to him so that he can determine whether the baby was stillborn or whether it was a neonatal death and whether an inquest should be called.
Emma added: "HM Coroner's observation that, if an emergency c-section had been performed sooner in accordance with timescales suggested by NICE guidelines, Ava would be with us today was particularly distressing.
"Hopefully the verdict of HM Corner will be taken to heart and acted upon by the hospital so that other parents will be spared the pain and emotional turmoil that we have had to endure simply to discover the truth about why our little baby girl's life was so short."
The hospital's medical director Martin Wetherill said: "The hospital fully accepts the coroner's verdict. We have said sorry to Ava's family for the unimaginable distress caused by the death of their daughter.
"Clinical staff made an error in classifying Ava as a stillbirth. It is important to recognise that since these tragic events that occurred in 2009, maternity services at Milton Keynes Hospital have undergone significant improvements that help to ensure such an incident should never occur again."