'ERRORS were made' during the care of a mother and child at Royal Bolton Hospital an inquest into the baby's death heard yesterday.

Mum Karen Higham-Deakin later said the experience had been a 'living hell'.

Her baby, Thea Rose Higham-Deakin was just 12 days old when the decision was made to withdraw care because she had suffered severe brain damage after being deprived of oxygen for 30 minutes during her delivery.

Coroner John Pollard said the care Thea and her mother received was 'sub-optimal' after it was revealed two midwives did not refer the case to an obstetrician. One midwife had only six months experience and the other had only worked one other shift in that hospital.

After the inquest, Thea's mother said: "I feel we trusted the staff at the hospital, the midwives and the Trust as a whole to do the best they could — to ensure that me and Thea were okay.

"But it was proven they didn’t do that. Obviously, no laws were broken, but they had a moral obligation to make sure they did their jobs and follow national and local guidelines, which was proven they did not do."

Midwife Linsay Wyatt described how she and midwife Aamena Hajee monitored Thea's heart rate during labour on June 23, 2015.

On more than one occasion the heart rate was outside accepted norms for a baby during labour, both too low, dropping at one point to 105 beats per minute and too high, at 165. She also described how on delivery the umbilical cord was around Thea's neck, but was 'loose enough to slip over' her head.

Expert witness, Patrick Forbes, a consultant at Addenbrooke's Hospital in Cambridge, was asked if he was critical of the decision by the midwives not to escalate care to an obstetrician. He said was not, although, he agreed with Bolton NHS Foundation Trust's representative, James Down, that it would not have been 'unreasonable' to do so.

Trust guidelines read out showed staff should refer cases to the obstetrician when the heart rate was outside accepted levels, however questions were raised about whether this was a hard and fast rule. Ms Wyatt admitted she was not familiar with the exact guidelines as she normally worked as a community midwife, but the guidelines were similar.

Since Thea's death, the trust has updated its policy and all members of staff are fully inducted when they start work in a new area.

Jill Pinnington, who wrote a serious incident report for the Trust, said midwives she had interviewed had also raised complaints about a booklet used to track labour.

Mr Pollard said he would write to health secretary, Jeremy Hunt to support the Trust trying to change this national practice.

Coroner John Pollard said: "It is quite clear that certain errors were made, the care could be described as sub-optimal.

"There was no evidence of anyone deliberately doing anything to cause mistreatment. There wasn’t any evidence of a really bad standard of care."

He added: "Karen was monitored and looked after in a midwife-led birth suite, at no time was she escalated to the care of an obstetrician and if she had been so escalated and an obstetrician had put her on monitoring and Thea delivered in 10 or 15 minutes, the outcome might have been different.

"We heard Mr Forbes say that. But he also said that there were really no grounds for escalating the care.

"The law is very clear, unless it can be shown that with further intervention her life would have been saved, I cannot conclude there was neglect."

Mr Pollard felt the cord was around Thea's neck before she was delivered at around 12.30am.

He said: "At times after about 12.05am it was apparent there were signs of terminal decline.

"The only significant thing would have been to try and deliver her as soon as possible and an episotomy, would only have been help if the head was presenting, even then the outcome was not guaranteed."

He concluded Thea died from natural causes after the compression of the cord in the womb led to severe deprivation of oxygen to the brain, leading to hypoxic-ischemic encephalopathy, or HIE.

Mrs Higham-Deakin added: "A number of opportunities were missed which we believe would have led to us taking our baby home. We asked for the inquest. For us it was never to attribute blame, it was to make sure practices were looked at. By their own admission, they have only recently done that. I feel our request was justified."

Mr Deakin and Mrs Higham-Deakin now have a three-and-a-half-month-old boy, Austin.

Trish Armstrong-Child, director of nursing and midwifery at Bolton NHS Foundation Trust, said: "Only someone who has been in the position of Thea’s parents can truly understand their pain, but on behalf of the hospital, I would once again like to give them our deepest condolences on the loss of their baby girl.

"There have been lessons to learn from this very sad event, and we have reviewed, updated, revised and audited relevant policies and record keeping so that the way in which mothers and babies are monitored is of a consistently high standard."