A couple from Northampton were forced to sue a hospital for negligence over the death of their son so the tragedy could be investigated independently.
Louie Buckley died about 30 minutes after his birth at NGH, which the hospital has only recently admitted liability four years later.
However, he was classified as stillborn, which means his death did not have to be reported to the coroner for an inquest.
As a result, parents Michelle Hemmington and Paul Buckley were left with no independent review of what happened - only NGH’s own internal investigation.
Michelle said: “We weren’t happy with the hospital investigating its own staff. It needs to be independent, but we weren’t allowed to have that.
“Any other death at a hospital would have been referred to the coroner, but stillbirths are not”
Michelle and Paul are now calling for every stillbirth from 37 weeks gestation that happens during labour to be referred to the coroner.
That way, a coroner can examine the facts objectively and, if necessary, hold an inquest, which can result in an order made to the hospital to prevent future deaths.
Michelle said “You can’t have a child die unexpectedly and be able to say: ‘It was just one of those things.’”
NGH finally admitted it was negligent last month, and was forced to pay damages, but only after four years of ongoing litigation by Access Legal.
The hospital has admitted 19 separate failings which led to Louie being stillborn - a classification the couple still dispute.
Some of these failings included failure to monitor foetal wellbeing, failure to escalate to a consultant obstetrician when urgent review was required and failure to conduct the initial resuscitation as per guidelines.
In the second stage of labour, Louie had become distressed and his heart rate was deteriorating.
Michelle raised her concerns and told the midwife she was struggling to deliver Louie.
But she was made to continue for an hour-and-a-half before the midwife intervened, with an episiotomy.
Louie was born moments later and placed on Michelle’s chest. However he was then taken to a resuscitaire and shortly after Paul and Michelle heard medical staff shouting for help.
Thirty-four minutes later, they were told Louie had died.
Michelle said: “My son’s cause of death is hypoxia (brain injury) due to lack of oxygen, something that could so easily have been avoided.”
NGH continued to deny negligence for four years and disputed liability, arguing that even if Louie had survived he would have been ‘neurologically comprised’.
However a spokesman for NGH said yesterday that the trust now admitted Louie’s life could have been saved.
He said “Every still birth is a deep tragedy for the family and all concerned. We have admitted that Louie should have been delivered sooner than he was and, had that happened, he would have been born alive.
“A very detailed internal investigation was undertaken and the circumstances surrounding Louie’s birth were also extensively examined by external experts, including an obstetrician and midwife.
“All the learning from those investigations has been implemented, leading to significant changes and improvements in our maternity services.”
Michelle is now campaigning for safer births (www.campaignforsaferbirths.co.uk/) and hopes that her work will help to change the law to give coroner’s jurisdiction to investigate these types of deaths.