A "cover-up" into failings surrounding the death of a baby girl who was treated at a scandal-hit health trust was "unforgiveable", say the child's parents.
Lesley and Gary Bennett spoke out at the conclusion of an inquest held more than nine years after their daughter's death in February 2004 at Furness General Hospital in Cumbria.
Her death certificate issued at the time stated she died of natural causes after no post-mortem examination took place and the coroner was not informed.
The family said they were told by a consultant six weeks later that their daughter's death was "just one of those things" and no lessons needed to be learned.
But last March her death was referred to South Cumbria Coroner Ian Smith in the wake of a police investigation into a number of baby and mother deaths at the hospital's maternity unit.
The police probe was launched three months after an inquest in June 2011 held by the same coroner into the death of baby Joshua Titcombe.
Mr Smith ruled Joshua died of natural causes nine days after his birth at the hospital in October 2008 but that midwives had repeatedly missed opportunities to spot and treat a serious infection.
Today, Mr Smith gave a narrative verdict on Elleanor's death in which she died "as a consequence of complications during the birthing process".
The inquest at Barrow Town Hall heard that Elleanor's heartbeat was not monitored by her treating midwife for 43 minutes before she was delivered and she then needed to be artificially resuscitated. She suffered continuous fits and was transferred to Liverpool Women's Hospital but died in her father's arms the next day.
National guidelines say fetal heart rates should be checked on at least every five minutes. After unsuccessful attempts to pick up a heart rate by midwives, the problem was then compounded as the doctor on duty was not called in to assist.
Mr Smith said it was not as if the doctor was unavailable to assess the situation.
"That would have given them the opportunity to get the baby out as soon as possible by whatever you means you can whether through forceps delivery or caesarean," he said. "That opportunity to get Elleanor out quicker was missed and obviously that was crucial to what happened."
He said it was "most likely" that Elleanor was starved of oxygen and suffered brain damage during the 43-minute period she went unchecked.
The hearing was told that an internal review was carried out by the health trust in 2004 and criticised the actions of midwife Marie Ratcliffe, who was sent on a two-day training course, but the Bennetts were unaware of the investigation.
Criticising University Hospitals of Morecambe Bay Trust, Mr Smith said: "I think someone should have bit the bullet and said (to the Bennetts) 'we really need to level with you and let you know why Elleanor did not survive' and they did not do that.
"The consequence of all of that is we are all here today nearly 10 years later carrying out an investigation that should have happened eight or so years ago."
Speaking after the hearing, the Bennetts, from Dalton-in-Furness, said: "In February 2004, our lives were devastated when our beautiful and precious little girl died at only 27 hours old. We were told that her death was one of those things and that no procedures could be changed to prevent it from happening again. With the help of family and friends we tried to rebuild our lives for the sake of our other children.
"In October 2011, the police came to our door to tell us that they were investigating a number of deaths at Furness General Hospital, and that Elleanor's was one of those cases.
"Since then, we have found out so much that was never revealed to us and this has totally devastated our entire family. We have had to restart the grieving process all over again.
"We are grateful to the Coroner, Mr Smith, for agreeing to hold an inquest. We now have the truth about what went wrong that night and this means we can try again to move on as a family and Elleanor can now rest in peace.
"We hope that lessons can be learned and that her death will not have been in vain. We urge the Government to ensure that the duty of candour is implemented and robustly enforced within the NHS. Our wish is that no family should have to go through what we have.
"We understand that nobody meant for this to happen, but to lie, cover up the mistakes and fail to learn from them is unforgiveable.
"We now ask for privacy to deal with our grief and move on with our lives."
The family's solicitor, Helen Budge of Pannone, said: "The loss of a child is a tragedy for any family, but Lesley and Gary Bennett have had to relive their grief as a result of the revelation, many years after Elleanor's death, that it might have been prevented. We hope that important lessons have been learned from this Inquest and would echo the family's plea for openness within the NHS."
The two-day inquest was told that the pregnancy of Mrs Bennett's third child went smoothly before she went into labour a week overdue.
She had been classified as high risk because of her high BMI (body mass index) and scans had showed it was anticipated to be a large baby.
Her waters were broken by a male registrar at 8.05pm on February 25 but he did not enter the maternity room again.
Ten minutes later, Elleanor's heart rate was recorded and appeared "perfectly satisfactory".
At 8.20pm the baby's head was noted as "visible".
Mr Smith said he was sure that Ms Ratcliffe thought the birth was imminent.
At 8.30pm, the midwife recorded "slowish progress, large head".
The coroner continued: "I think at the moment she was thinking the baby would come any minute but it did not."
He added: "I think time just sort of slipped away."
The inquest was told that attempts were made to find a heartbeat via a cardiotocography (CTG) machine and a hand-held sonic aid device but to no avail.
At 8.45pm Ms Ratcliffe asked a senior nursing colleague for help who took charge and Elleanor was born at 8.58pm.
Giving evidence, Mrs Bennett said Elleanor - who weighed 10 pounds and 10-and-a-half ounces - was placed on her stomach but she noticed her newborn daughter was blue in colour and her head flopped when she touched her shoulder.
Following Elleanor's death, an internal investigation by the trust's then head of midwifery, Denise Fish, took place.
The coroner said it was "thorough" and "pulled no punches".
A memo written by Miss Fish as part of the review stated if the case went to litigation then expert witnesses would certainly query the 43-minute gap in the heart rate measurement.
It went on that if she did not know that Ms Ratcliffe was a competent and experienced staff member then she would have concluded "there was negligence by omission".
The coroner remarked: "That is a very straight and damning piece of evidence which said there was a delay and there should not have been."
Mr Smith said the Liverpool coroner should have been informed of Elleanor's death at the time.
The inquest heard evidence that both hospitals agreed between themselves that it did not need to be passed on.
"It would have been out in the open," said the coroner. "It might have opened people's eyes a bit in maybe 2005 and maybe it would have made people stop and think some more."
He said he would write to the Chief Coroner and the Department of Health about a "flaw in the system" where deaths were not necessarily referred after patients were transferred to other hospitals.
He would also write to health bosses about the problems highlighted at the maternity unit surrounding the birth of Elleanor.
Earlier this month, Health Secretary Jeremy Hunt announced an independent inquiry would take place into the management, delivery and outcomes of care provided by the University Hospitals of Morecambe Bay Trust's (UHMBT) maternity and neonatal services between January 2004 and June 2013. Care Quality Commission (CQC) officials have been accused of covering up a failure to properly investigate UHMBT, which runs Furness General.
Police in Cumbria say they are just investigating the death of Joshua Titcombe after ruling a number of other deaths - reportedly up to a total of 16 - at Furness General they probed would not be subject to a criminal prosecution.
Mr Titcombe, who attended today's hearing, said: "This is another case here of midwives not involving doctors, going back to 2004.
"Clearly if things could have been done at the time to improve the situation then Joshua and other babies may have been here today."
Last week Mr Titcombe was appointed by the CQC as a national adviser on quality and safety. Liza and Simon Brady, from Walney Island, also attended the inquest and said their son, Alex, died in "almost exact circumstances" to Elleanor in 2008.
Alex was stillborn with his umbilical cord around his neck and his inquest found midwives - including Ms Ratcliffe - did not involve doctors early enough during Ms Brady's labour.
The couple said they were "very disappointed" that the coroner did not link their son's death to that of Elleanor in his summing up.
Ms Ratcliffe, who is still employed by the trust, was also involved in the delivery of Joshua Titcombe.
George Nasmyth, Medical Director of University Hospitals of Morecambe Bay NHS Foundation Trust said: "We extend our sincere condolences to Baby Elleanor Bennett's family. For any family to lose a loved one is an absolute tragedy and having to revisit a very painful time from 2004 is extremely difficult. Our heartfelt sympathy goes out to them.
"We acknowledge that full information wasn't shared with the family at the time of Elleanor's death and we apologise for this. We have now improved our systems to ensure that in similar circumstances, information is shared with the family concerned as soon as possible.
"We have accepted that some of the care provided to Mrs Bennett in 2004 during the course of her labour and delivery was inappropriate and that steps should have been taken to deliver Elleanor sooner.
"We fully accept the Coroner's conclusion that Elleanor died as a result of complications during the birthing process, and we are sincerely sorry for this.
"We acknowledge the Coroner's intention to issue a Prevention of Future Death Report focusing on the notification of deaths of patients who have been transferred to other hospitals and we will co-operate fully with any recommendations made in that regard.
"We recognise that currently a national process is not in place to ensure this happens and it is often done between professionals on an informal basis. We would welcome the opportunity to work with partners across the NHS to develop national guidance and standards in respect of this. We believe this would ensure the clinical outcomes of patients who are transferred are fully investigated when appropriate in line with the duty of candour.
"During the last 12 months significant progress has been made with a new Trust Board in place and clinicians leading changes in the way we operate. A new clinical leadership team for our maternity services has a clear vision of providing safe and excellent care which will meet the needs and expectations of mothers and babies."