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25 February 2016, 06:36 | Updated: 25 February 2016, 07:04
A report into mistakes made in the care of a baby from Shropshire - has found a midwife altered notes after the baby had died.
Richard Stanton and Rhiannon Davies's daughter Kate Stanton-Davies died shortly after delivery at Ludlow Community Hospital in Shropshire.
Midwives failed to spot Kate was becoming desperately poorly and wrapped her in "warm clothes'' instead of realising she needed an incubator.
A report by NHS England, which is the second carried out, concluded her death was avoidable.
Two midwives on duty at the time have been recommended for disciplinary action, a third should be supervised and a fourth should receive more training.
A midwife who altered clinical notes in the aftermath claims she was told to do so by a supervisor who initially investigated events and there was no staffing policy in place.
Ms Davies told the Health Service Journal, "The biggest regret of my life is that I trusted the trust, its midwives and its managers. I trusted that they had policies in place, training, staffing and safe practices. I took them at their word, I never once questioned them, and it cost my daughter her life.''
Simon Wright, chief executive of the trust, said: "We fully accept the findings of this report, which has been carried out by NHS England, and see it is an important part of the learning process following the sad and tragic death of Kate Stanton-Davies in 2009."
An NHS England spokesperson said: "This tragic case seven years ago underlines the importance of the recommendations from the independent Maternity Taskforce about transparency, teamwork and learning, and we continue to work with the family, the Trust, NHS Improvement and the local commissioners to ensure that action is being taken accordingly."