A six-month-old baby died after their mother was given incorrect advice by a member of staff at a hospital in Stoke-on-Trent.
The mum phoned the maternity assessment unit at the Royal Stoke University Hospital seeking medical advice about her child.
But the call was taken by a maternity ward clerk rather than a registered midwife - resulting in the incorrect advice being given.
University Hospitals of North Midlands NHS Trust (UHNM), which runs the hospital, has since recruited more registered midwives to ensure there is always one available to provide telephone triage.
The incident - which happened last June – has been reported to this month’s trust board meeting.
Director of midwifery at the UHNM, Sarah Jamieson, has described the neonatal death as a "very sad case".
Ms Jamieson said: "The lady made a telephone call to maternity, and the phone call was taken by a ward clerk and not a registered midwife, and unfortunately some incorrect advice was given to the mother.
"This case underwent a perinatal mortality review, as all neonatal deaths do, and there were some immediate actions that we pulled out from that.
"Clearly we've adhered to our duty of candour with this case, and that was completed."
She adds: "Maternity services have now recruited 3.64 whole-time equivalent midwives, and that's to assist and to provide a 24/7 telephone triage service, so that midwives are taking those calls and giving advice as required.
"The maternity assessment unit is an incredibly busy unit, we see 60, 70, 80 women. It is our emergency department for maternity services.
"So it's incredibly important that we cover that service with a registered midwife at the end of the telephone line."