Kate Stanton-Davies death: Trust 'failed to establish facts' around death
A hospital trust "abdicated its responsibility" in finding out why a baby died six hours after her birth, an independent review has found.
Kate Stanton-Davies died after delays transferring her from Ludlow Community Hospital, in Shropshire, to a doctor-led maternity unit in March 2009.
Shrewsbury and Telford Hospital Trust (SaTH) "failed to establish facts and accountability", the review said.
Chief executive Simon Wright apologised "unreservedly" for the shortcomings.
Kate, who had anaemia, was born "pale and floppy" and died after being taken by air ambulance to Birmingham's Heartlands Hospital.
Repeated signs the pregnancy was not low-risk were not picked up and her death was avoidable, an earlier NHS England-led review found.
Serious concerns about the fitness to practise of two midwives were also raised.
The purpose of the current review was to determine whether the trust fulfilled its responsibility to establish the facts about why the death occurred.
In conclusion, it stated the trust had not carried out a "robust managerial investigation", failed to hold staff to account and failed to address concerns raised by Kate's parents, Richard Stanton and Rhiannon Davies.
Without the couple's tenacity in seeking the truth of the circumstances, vital lessons would not have been learnt, the report said.
"For this, the trust is indebted to Ms Davies and Mr Stanton," it stated.
"The trust should work in partnership with Kate's parents to establish a fitting acknowledgement of the contribution they have made to the safety and quality of maternity services at SaTH."
Mr Wright from the trust said: "We fully acknowledge the failings identified in this report and the harm they have caused to Richard and Rhiannon."
Ms Davies told BBC News they felt they have had the answers for "a long time", but have been battling to get the hospital to accept them.
"Over the years, they have constantly been telling us to go away and that our concerns were unfounded," she said.