A baby who lived just 27 minutes would have survived if his mother was not turned away twice by the nearest hospital, a coroner ruled.
Archie Batten died after a prolonged labour at home after his mother Rachel Higgs was twice refused admission to Queen Elizabeth the Queen Mother (QEQM) in Margate, Kent.
Neglect contributed to the death and said there were a string of missed opportunities that led to complications during delivery over a 10-hour period, a coroner found on Friday.
Ms Higgs was refused admission at the QEQM on September 1, 2019, on the basis she was not in active labour, despite suffering from pain and vomiting.
The first-time mum was then told to go home and "wait as long as possible" before returning, when a bed would then be available.
But when almost fully dilated at 9cm later that day, Ms Higgs and her partner Andrew Batten, were again turned away, this time due to the hospital being on "divert" because of a lack of beds.
The coroner heard the couple were told to drive the 38 miles to the William Harvey Hospital in Ashford, Kent.
Rather than make the hour-long trip while on the verge of giving birth, community midwives were sent to their home.
Ms Higgs, who had enjoyed a previously uncomplicated pregnancy, spent five hours trying to push out Archie during a prolonged and complicated labour.
She became dehydrated and her baby became stuck and unable to turn during labour, an inquest heard.
None of the midwives realised labour needed to be progressed and Archie delivered, according to Ms Higgs' solicitor Nick Fairweather from Fairweathers Solicitors LLP.
Her membranes were only broken at a very late stage and there was a failure to keep proper records of the foetal heart rate.
She started to give birth at home and an ambulance was finally called once the severity of the situation was realised by one of the midwives.
The QEQM's maternity unit had in the meantime been reopened but this had not been communicated to the midwives.
By the time Ms Higgs reached the QEQM Archie was born, but in a very poor condition.
He managed to breathe independently for a short time but tragically died after resuscitation attempts failed.
Concluding the inquest on Friday, coroner Sonia Hayes found neglect contributed to the death and said there was a number of missed opportunities which led to complications in labour.
She said: “I find there were multiple missed opportunities to render care to Rachel and as a consequence to Archie, that were obvious and not only would have made a difference but would have prevented the death of Archie.
"Failures amounted to gross failures to provide basic medical treatment. There were a number of missed opportunities to avoid the prolonged labour.
"There were failures in communication between the midwives at the maternity unit, and those involved with the treatment of Rachel at home.
"Not one of the midwives spoke with Rachel about her wishes or the circumstances she found herself in.
"The wishes of the mother were not sought or taken into consideration. The decision for a homebirth was made for her without any discussion."
She ruled that he would have survived and been born without neurological defects if he had been admitted to hospital.
In a statement after the ruling Ms Higgs and Mr Batten said: "It seems incredible to us that so many basic mistakes were made by so many people
"Archie would be two and a half years old now. We think about him and miss him everyday and always will.
"Nothing can bring him back to us, we can only hope that true lessons will be learned from this case and lasting changes made to ensure other families do not suffer such tragedies in the future."
Archie's medical cause of death was recorded earlier in the nine-day inquest as being due to a perinatal hypoxic-ischemic brain injury caused by prolonged labour.
In August 2020, almost a year after his death, East Kent Hospitals Trust admitted its care was substandard and that Archie would have survived without any kind of injury had he been delivered earlier.
During the multi-day inquest in Maidstone, Kent, the court heard how basic observations were not regularly carried out during the ordeal, that record-keeping was "extremely" poor and that there was a delay in getting Ms Higgs to hospital when labour failed to progress.
Ms Higgs was almost fully dilated at 5pm and was expected to give birth within two hours, which is the average length of pushing time for first-time mothers.
Yet it wasn't until after 10pm that an ambulance was called by the community midwives, after they realised there was a problem with the foetal heart rate, sparking an "obstetric emergency".
Giving evidence last month, midwife Nikki Khan, told the hearing how issues during Archie's labour could have been "corrected" and the outcome "completely different".
She said on the balance of probability Ms Higgs was dehydrated and possibly hyperstimulating - a condition caused when the ovaries adversely react to too many hormones and become swollen and painful - with the baby stuck and unable to turn.
Ms Khan said: "These are all indicators that she should have come to hospital early. The dehydration and malpositioning could have been corrected had she been transferred earlier.
"Strong Syntocinon [a drug used for induction of labour] could have been administered and Archie would have been delivered quickly."
a composite graphical record of key data
She said basic observations such as testing Ms Higgs' urine with a dipstick, taking blood pressure regularly, monitoring her fluid intake and the starting of a partogram graph to record data and timings were not carried out.
Ms Khan said she believes dehydration played a "massive part" in what happened.
She added that due to record-keeping not being as it should be, "we don't know the full story" regarding the foetal heartbeat.
At the conclusion of the inquest into the death of Archie Batten, Tracey Fletcher, Chief Executive of East Kent Hospitals, said: "On behalf of the Trust, I apologise unreservedly to Archie’s parents and family for Archie’s death.
"We fully accept the Coroner’s findings and conclusion today and we are deeply sorry for the failings in the care provided to Archie and his family in September 2019.
"We have made - and continue to make – changes and improvements to the quality and safety of our maternity service.
"Since Archie’s death, we have made changes to how we care for women and babies during a homebirth; and to how we provide the service when the hospital maternity units are busy.
"The lessons from Archie’s death, and the findings of the independent investigation into our maternity service being led by Dr Bill Kirkup, will be built into our continued improvement, to ensure we provide high-quality maternity care for families in East Kent."
Archie's death is one of a number of potentially avoidable baby deaths at crisis-hit East Kent Hospitals.
An independent inquiry called the Kirkup Review is currently underway with an expert panel looking at the performance of EKH dating back to 2009, when it became a foundation trust.
Families who believe they received poor clinical care from the trust were encouraged to come forward and the number is believed to be at almost 200.
The findings of the investigation are expected to be published after the summer.
In 2020, the hospital trust's board admitted the number of potentially avoidable baby deaths could be as many as 15 in seven years.
