An inquest has ruled that the death of a newborn baby girl could have been avoided had she been delivered in hospital and not in a midwife-led unit.
Kate Seren Stanton-Davies died just six hours after her birth at the Ludlow Community Hospital.
After suffering a collapse two hours into her life, she was flown to Birmingham Heartlands Hospital, but later died.
Her mum, Rhiannon Davies, 38, had suffered complications in the last month of her pregnancy, and had undergone tests and appointments at hospital. Despite having a rare condition which meant blood leaked from her unborn baby into her, it was decided she was low enough risk to have her child at the midwife-led unit.
An inquest jury at South Shropshire Coroners' Court unanimously concluded on Friday that baby Kate would have survived if her mum had given birth elsewhere. They said the decision by medics to treat Rhiannon's pregnancy as low risk contributed to Kate's death.
Mrs Davies said: "Lessons must be learned and change implemented to ensure no other family has to endure what we have been through.
"Throughout my pregnancy and Kate's birth we, as a family, have been let down by the various organisations within the NHS."
She added that knowing what the family now know, she would have 'never have consented to have given birth at Ludlow maternity unit'.
"We have grave concerns about the quality of midwifery care that Kate received after her birth," Mrs Stanton said.
Following the inquest we now know that she was left alone in a cold cot in a hypothermic state with signs of respiratory distress by a midwife who was meant to be caring for her. That image haunts us.
Kate's dad, Richard Stanton, 42, told the Sunday Times that 'the hospital trust were, and are responsible for the death of our daughter'.
"The questions we have been battling to get answered for three years and eight months have finally been answered by a unanimous jury verdict," he said.
Cathy Smith, head of midwifery and deputy centre chief for the women and children's centre at The Shrewsbury and Telford Hospital NHS Trust told reporters after the inquest that the hospital would now be 'taking the time to reflect on the jury's findings'.
The couple's solicitor, Ian Cohen, of Goodmans Law, said that 'lessons must be learnt, but it is of critical importance that mothers-to-be are fully informed and give full and informed consent'.
The hearing had also been told of a series of catastrophic logistical arrangements the couple endured as they tried to rush to their daughter's bedside after she was flown to Heartlands Hospital. West Midlands Ambulance Service reportedly refused to treat her mother as a priority, and informed the couple they might have to wait four hours to be taken by ambulance to be with Kate.
The couple then decided to drive themselves to Birmingham and attempted to follow the helicopter by car, but Rhiannon Davies collapsed during the journey and an emergency ambulance had to be called which then transferred her to Worcester Hospital.
Mr Stanton eventually discovered where his daughter was being treated after phoning round all the hospitals in the area. He arrived at Heartlands for the last five minutes of her life, but the little girl's mother did not make it until 90 minutes after she had died.
Dr Andrew Carson, medical director for the West Midlands Ambulance Service, said in a report that 'logistical and procedural issues within WMAS led to an unsatisfactory experience for this family at a time of great difficulty for them.'
Responding to the statement, Mr Stanton said: "If one flies with a budget airline one might have an unsatisfactory experience. But the fact that it took 58 minutes from the 999 call being made to Kate arriving at Heartlands Hospital, where she died in my arms, makes this comment grossly inappropriate."
West Midlands Ambulance Service released a later statement saying they did all they could to save Kate. Spokesman Murray MacGregor said: "The inquest has shown that the care provided by the ambulance crew and the doctor and paramedic on the air ambulance was appropriate and they did everything they could to get Kate to Heartlands Hospital in Birmingham, a Level 3 neonatal unit, in the shortest possible time."
Devastated Mr Stanton said: "Ultimately... my daughter would only be alive today if the clinicians from the Shrewsbury and Telford Hospital Trust had listened to mine and my wife's concerns about our baby, both before she was delivered and immediately following her birth."