The death of a newborn baby in a hospital at the centre of a police investigation may have been avoided if she had been transferred sooner to a specialist unit, an inquest heard on Thursday.
Amelia Bower died later the same day she was born last April at Furness General Hospital in Cumbria.
Complications set in during the birth as she became "extremely ill" but her chance of survival "would clearly have increased" if she had been moved earlier to a specialist centre elsewhere in the North West, ruled South Cumbria coroner Ian Smith.
The youngster had the natural misfortune of having her umbilical cord wrapped around her foot in the womb which curbed blood and oxygen supply.
This led to her ingesting a substance called meconium, early faeces usually passed after birth, while still inside the uterus.
Recording a narrative verdict, Smith said: "The cause of death was meconium aspiration.
"Amelia Jade Bower died as a consequence of ingesting meconium before birth and she was not transferred to a specialist regional centre where advanced resuscitation techniques were available."
The child's mother Kelly Hine, from Dalton-in-Furness, was up to 10 days overdue when she gave birth by caesarean section in the early hours of April 3.
When her waters broke it was noted they were heavily stained with meconium and a foetal blood sample was judged to have been "very abnormal".
A paediatric specialist registrar and an on-call clinical paediatric consultant later viewed an X-ray of the baby in which the former told her senior colleague she thought that meconium had been ingested but the consultant saw it as "normal".
The hearing at Barrow Town Hall heard that the consultant returned home, as he adopted a "wait-and-see approach" rather than recommend an immediate transfer of Amelia from Furness General.
The consultant, Dr Saeed Ghanian, is currently working to restricted duties as an internal inquiry by the hospital continues.
The coroner emphasised it could not be known whether she would have survived and it may have been that her condition was not stable enough for the transferral to take place.
Police officers from Cumbria Constabulary were in attendance each day of the three-day hearing.
It emerged an inquiry into "a number of deaths" at the maternity unit was under way following another inquest held by Smith last June into the death of Joshua Titcombe, of Dalton, nine days after his birth at the hospital in October 2008.
He ruled Joshua died of natural causes but that midwives had repeatedly missed opportunities to spot and treat a serious infection.
Then the trust, University Hospitals of Morecambe Bay NHS Foundation Trust, was criticised by the Care Quality Commission (CQC) after inspectors carried out surprise inspections.
In February chief executive Tony Halsall resigned after going through what he said was "an extremely difficult time".
Detectives have not revealed the exact number of deaths they are studying but it has been reported on numerous occasions the probe is covering the deaths of at least two mothers and five children.
Earlier this month another mother died after being treated in the maternity unit. Carly Scott, 26, lost her life a week after giving birth to her first child, George.
The inquest heard that paediatric specialist registrar Dr Sarrah El-Munshid had later reported to her bosses that, on the day of Amelia's admission. there was "very little support" for her, with no junior cover, and that she was also dealing with two other sick children on the high-dependency unit.
Smith said nurses on the ward were also voicing concerns that Amelia should have been transferred earlier from Furness General.
"Dr Ghanium's decision was to wait and see," he said. "I have to say that, if Amelia had been transferred earlier, then her chances of survival would clearly have increased.
"We cannot say she definitely would have survived."
He added that Dr Ghanium was not aware of the results of the foetal blood sample as Hine's medical notes were not joined up with her daughter's notes.
The coroner said: "There was kind of an assumption that everyone knew the figures and no-one told Dr Ghanium.
"He says had he known that (then), his management would have been completely different. It appears it fell through the cracks."
He noted that the trust had made an unreserved apology to the couple.
"I think they have taken on board what they needed to," he said. "Their approach and attitude to what happened and to this inquest is that they have clearly been affected at what occurred and they have made changes."
The hearing was told that among the changes were that more midwives were now present at any one time in the maternity unit and that staff had the option of voicing concerns to a consultant at all times if they disagreed with the views of a senior member of staff.
Smith told Hine and her partner, Carl Bower: "I ask you to remember her (Amelia) as an individual and not remember her in terms of the medical events that very sadly were a great part of her life."
Speaking after the hearing, Julia Hurstfield, of law firm Pannone, said on behalf of the couple: "We are very grateful to the inquiry because it has answered the questions that we had when Amelia was born and confirmed what we felt at the time - that the care was not appropriate.
"We have accepted the apology and we are glad that lessons have been learned."