A coroner today branded midwife shortages at a hospital where a newborn baby died on an overstretched maternity ward as "nothing short of scandalous".
Deputy coroner for Milton Keynes Thomas Osborne said "systems failures" contributed to the death of Ebony McCall at Milton Keynes General Hospital in May this year.
An inquest at Milton Keynes Civic Centre heard the baby girl, who was full-term, only had a faint heartbeat when she was born by Caesarean section. She died minutes after her birth.
Her mother, Amanda McCall, who was 17 at the time, suffered medical conditions, including cardiac disease.
Miss McCall, who has only one kidney, was admitted to hospital on May 8 with stomach pains.
An ultrasound showed the cause was swelling in her remaining kidney and Miss McCall, who also suffers a narrow pulmonary valve, was advised to have an induced birth to ease her symptoms.
She refused because of the pain and requested a Caesarean section but was told these could only be given at night if they were emergencies.
Miss McCall, now 18, naturally entered labour that night but the baby's heartbeat became erratic, necessitating the emergency Caesarean she had wanted in the first place.
But Ebony, who was born at 3.21am on May 9, died at 3.35am.
The three-day inquest has been told of staff and bed shortages at the hospital, which has previously come under fire.
Deputy Coroner for Milton Keynes Thomas Osborne last year reported the hospital to the Department of Health after the death of baby Romy Feast, who was born by Caesarean section at the hospital in 2007 but died after her cardiotocography (CTG) was misinterpreted.
Following his referral, a Healthcare Commission investigation was launched.
Today, Mr Osborne said the 2008 report found many recommendations had not been met.
Recording a narrative verdict into Ebony's death, he said: "The situation where mothers are left unattended during labour and other mothers are unable to get an epidural is nothing short of scandalous.
"If this situation is allowed to continue the lives of babies and mothers who intend to have their babies at Milton Keynes Hospital will continue to be at risk."
Mr Osborne said he planned to write to the Health Secretary about the situation and to suggest a task force is put in place.
He told the inquest: "Amanda was obviously a very apprehensive young expectant mother.
"She had spent a great deal of years prior to the pregnancy in and out of hospital."
He said the teenager had suffered a heart condition, curvature of the spine and only had one functioning kidney.
He said: "It is surprising that in view of her classification as high-risk she was not seen by her consultant until the day before she came into hospital to deliver her baby.
"The situation on the labour ward became what has been described to me as 'chaotic' with far too many mums and not enough midwives."
He said during the inquest, experts had pointed out the "inadequate" monitoring of Miss McCall and it had emerged that despite recommendations that bed numbers were increased to 47, there are still only 30.
The inquest heard that between January 2007 and October 2009 there were 2,114 incidents reported on the labour or maternity wards and of those, more than 25 per cent related to staff shortages.
"Anyone who has listened to the evidence cannot help but be appalled by the pressures that are placed on midwives," he added.
Today Amanda's mother, Breda McCall, told the inquest the death had left her daughter devastated.
She said: "Amanda is emotionally a mess. She will never return to normal. She will never be the same girl she was the night before she went in there."
The inquest heard she sounded the panic alarm when she saw a monitor of the baby's heartbeat spike, and it was then that her daughter was taken for an emergency Caesarean.
While Amanda was in theatre someone returned to tell her "mother and baby were both fine" but later she was taken to theatre to see medics resuscitating Ebony.
She said: "I could see them through the door, I knew then that she was going to die."
She said Ms Gupta later told her: "If only you had pushed that button five minutes earlier you would have saved your granddaughter."
She said: "I remember these words because I think of them every morning and every night."
Mrs McCall said her daughter's grief was compounded by the fact she was kept on a labour ward for a further eight days after Ebony's death.
Today, hospital staff admitted the standard of care received by the teenage mother had not been as high as it should have been.
Miss McCall's consultant, Anthony Stock, told the inquest: "I am happy to acknowledge that the care did not come up to a standard that I would have expected normally for a patient booked in my name.
"I think everyone acknowledges within the department that we do need to have higher staffing levels and more space."
Head of midwifery services Elizabeth Hunter said: "I fully acknowledge that with the complexity of the circumstances that night the systems did not support us in ensuring the standard of care and safety that we would have wished."
Midwifery education consultant Carol Bates told the inquest the care Miss McCall received was "erratic".
She said: "Someone should have thought that maybe this is labour and carried out an internal examination at some point."
She said there were insufficient midwives on duty that night, adding: "I think there does need to be some kind of investigation to assist the Trust."
Earlier today, also at Milton Keynes Civic Centre, Mr Osborne opened and adjourned an inquest into the death of another baby born at Milton Keynes General Hospital.
Speaking after the inquest, Amanda's father Terry McCall said: "I really don't know what to say under the circumstances.
"The family and I are very relieved that the coroner has referred it back to the Secretary of State.
"Hopefully it will make things safer for other women giving birth in Milton Keynes.
"There seems to be no reason that Ebony died. She was born at full term and she was a healthy 7lbs 4oz and even thought she had a slight infection had the problems been picked up it's likely she would have been with us now, celebrating her first Christmas.
"I am absolutely enraged to think that there was no reason for Ebony's death.
"The review can't come quick enough to try to keep people safer but the review will only work if the recommendations are put in place."
He said Ebony's death had had a devastating effect on the family.
He added: "During the summer instead of going around walking our new granddaughter in her pushchair we were having to go round cemeteries with Amanda as she decided where to bury her.
"The family is not interested in Christmas now, it's just not going to be the same."
Milton Keynes Hospital NHS Foundation Trust today apologised for the distress and grief caused.
Tony Halton, director of nursing at the trust said: "On behalf of the Trust I would like to offer the McCall family our deepest condolences.
"I would like to reassure mothers and families that the delivery of safe, quality care is the Trust's key priority. We continue to work hard to improve the maternity services that we provide to local people.
"We have already made changes to the way we work to further improve the safety of our services."
The Care Quality Commission health regulator said the coroner's findings would be used in a follow-up to the 2008 report on the maternity unit.
It will review progress made by the trust against 12 recommendations for improvement published by CQC's predecessor, the Healthcare Commission, last December.
The report said a lack of resources, mainly in the number of midwives and bed capacity, was putting maternity services at risk.
Amanda Sherlock, deputy director of frontline operations at the CQC, said: "The death of Ebony is an absolute tragedy.
"The Trust must learn and do everything possible to ensure the same thing does not happen again. It is clear that the unit was insufficiently prepared to cope with the pressures on that particular night and that Ebony did not get the care she needed as a result.
"We do believe there have been improvements since last year's assessment, in particular in the areas of clinical governance and leadership. But we are absolutely clear that more needs to be done, particularly in the areas of increasing numbers of midwives and learning from serious incidents.
"The trust must respond quickly on all of the recommendations. While care has improved in some areas, faster improvements need to be made in other parts of the service. It must get its procedures right every day, for every mother and baby. It must plan for high levels of demand and ensure it has systems in place to cope at all times.
"We would not hesitate to take further action if we felt it were necessary. We will be reporting in full on the findings of our recent inspection and assessment activity. We will continue to closely monitor progress together with key partners including the PCT, SHA and Monitor, until we have full reassurance on all the concerns raised by the coroner."