An inquest has found systemic failings at the Cwm Taf Morgannwg health board led to the "preventable" death of a day-old baby.
Nelly Webb was born prematurely via C-section and died on 2 January 2019 at the Royal Glamorgan Hospital in Llantrisant.
The inquest at Pontypridd Coroner's Court heard Nelly was "rescuable", if the right treatment had been given at the right stages.
Diane Rostron, birth injuries solicitor, said Nelly's parents Jessica and Rikki Webb, welcome the coroner’s finding and are pursuing a medical negligence claim against the hospital.
The health board told ITV News Wales that it fully accepts the findings and has apologised to Nelly’s family "for failings in care".
The coroner heard "serious concerns" over the health board's maternity services were known, nearly a year before Nelly was born.
The inquest also heard concerns about the maternity department were raised nearly a year before Nelly’s death.
More than a year later, they were told by the health board that mistakes had been made in Nelly's care.
Jessica and Ricky have since had two sons but said they are "deeply traumatised by what happened" with their first-born, Nelly.
“Jessica and Rikki lost their first born little girl in circumstances that could have been avoided. They have been left deeply traumatised by their loss.
"We hope that this finding leads to key learnings."
Allison Williams was the health board's chief executive at the time.
Ms Williams was questioned on the second day of the inquest and explained that she first became aware of concerns about the maternity unit in July 2018.
She apologised to Nelly's parents and admitted that Jessica should have been transferred to a specialist unit to give birth because her baby was born too soon.
Ms Williams told the hearing: “It is heart-breaking for the family, I am sincerely and genuinely sorry for everything they had had to go through”.
At the time of Nelly's death, there was a "serious shortage" of midwives, according to Ms Williams.
She added that there was also a reliance on some doctors, who were still in training.
Ms Williams resigned after an extended period of sick leave following the publication ofa damning report in April 2019 into the maternity services at the Royal Glamorgan andPrince Charles Hospitals.
The health board's current chief executive, Paul Mears, said the loss of a baby "is devastating, and we do not underestimate the pain that her family continues to suffer as they come to terms with their loss".
He added that the health board is "committed to learning from such tragic events to ensure that they do not happen again".
“Since 2019, we have made significant changes to maternity and neonatal services in our Health Board.
“Our neonatal units are now located at Prince Charles and Princess of Wales Hospitals, each with a dedicated consultant and a specialist neonatologist, increasing the level of senior clinical leadership on our units every day of the week.
“Our training and education programme for all staff has been expanded to cover a broader range of neonatal skills, procedures and simulation-based training and all of our teams have access to the latest clinical policies and guidelines.
“Systems are also in place to strengthen joint working between our maternity and neonatal teams and, through improved clinical data, we continually monitor outcomes and quality, enabling us to respond quickly to improve the safety and effectiveness of the care we provide."
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