The death of a newborn baby at Furness General Hospital in Cumbria may have been avoided if she had been transferred sooner to a specialist unit, an inquest has heard.
Amelia Bower died later the same day she was born last April the hospital. 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.
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.
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 Mr Smith last June into the death of Joshua Titcombe, of Dalton, nine days after his birth at the hospital in October 2008.