THE inquest into the death of a five-day-old baby has ruled she died of natural causes, despite the "serious failings" of midwives.

Poppy Rushton was born at Furness General Hospital on March 3 2016, but was born "pale and floppy" and needed resuscitation immediately after her birth.

After a week of evidence at Cockermouth Coroner's Court last month, area coroner Kally Cheema ruled Poppy died of natural causes as a result of umbilical chord compression in the course of delivery, which led to a severe acute hypoxic ischaemic insult from which she did not recover.

Miss Cheema went through the evidence given over five days and highlighted various failings and conflicting interpretations of events, but said: "I do not find that there was a gross failure to provide basic medical care."

In her conclusion she said: "I find that the midwives failed to call the obstetrician when they should have done.

"Whilst the interpretation of CTGs may be difficult, the failure to call the obstetrician was a basic medical issue.

"Even if this had been the case, and Mr Sunday Ajayi had returned, on my findings this would not have made any difference.

"However serious the failings of the midives were, the chain of causation between those failures and the cause of death is broken.

"Therefore I will return a narrative conclusion without the rider of neglect."

In her conclusion, Ms Cheema said both midwives were adequately trained and competent to provide the necessary care, but pointed out that communication between them at a critical time was "poor".

Regarding Miss Biggs using her fingers instead of a stethoscope to check the bay's heart rate, Ms Cheema said that method was "unreliable and in breach of Trust policy".

She pointed out that amendments by the midwives to APGAR score, made retrospectively, gave a false impression of Poppy's condition after delivery.

Poppy's parents, Michael and Kayleigh Rushton, had earlier described their daughter as "pale and floppy" when she was born.

Miss Cheema said Mrs Calderbank's failure to obtain cord blood gases was in breach of trust policy and, as the senior ward co-ordinator on the night, Ms Biggs should have ensured it happened.

She also ruled both midwives failed to retain the placenta for histological examination.

After Poppy's death, Ms Biggs was suspended, and then sacked, by the University Hospitals of Morecambe Bay NHS Foundation Trust, and struck off by the Nursing and Midwifery Council after her role in the death of Joshua Titcombe in 2008 and for refusing to co-operate in the investigation into Poppy’s death.

Giving evidence at the inquest, Mrs Calderbank wept as she told the court of the agonising wait for the newborn to take her first breath.

She said: "I have delivered babies that are just stunned and then take a deep breath and start crying.

"She was just trying to get her breath and it never happened.

"Reflecting back there are times I wish I had asked for Lindsey to stay in the room, but I did feel supported at the time."