Medical staff delayed taking a pregnant mother for a caesarean section and did not mention the umbilical cord had been detached hours before her baby tragically died.
Kirsty Carleton and her husband Chase were expecting to welcome a healthy baby boy into the world when they arrived at Liverpool Hospital on August 8, 2018.
However, a number of unexpected medical emergencies and deficiencies in the hospital's operations took place before their son Everett died hours after an emergency C-section.
A coronial inquest into the death was held at Lidcombe Coroner's Court with findings released on Friday.
Deputy State Coroner Carmel Forbes found the newborn died in the context of a high-risk pregnancy, a delayed delivery and damage to both the placenta and umbilical cord.
After an ultrasound scan in the lead-up to the birth, a doctor at Liverpool Hospital recorded the incorrect location of Mrs Carleton's placenta by accidentally using the wrong drop-down box to generate the report, Ms Forbes found.
However, even if the position was correctly recorded, it would not have changed the hospital's decision to admit the expecting mother into the operating theatre for the C-section, the coroner said.
During the operation, which started almost an hour after an emergency caesarean was called for, the placenta was either unintentionally cut or it separated from the wall in a process called an abruption.
This caused excessive bleeding.
Ms Forbes was told during the inquest that abruptions could not be trained for and occurred without previous symptoms.
The umbilical cord also detached at two points, although the coroner was unable to determine the cause.
But she found the hospital's neonatal intensive-care unit was not told of the detached umbilical cord.
"There was no effective communication on this issue," she wrote.
There were also "serious staff shortages" at the hospital and no equipment available to monitor Everett's heart rate as his mother waited to go into the operating theatre, Ms Forbes found.
Since 2018, Liverpool Hospital had dealt with the staffing issues, purchased the required equipment and updated its policies to allow for better communication between teams, the coroner noted.
While the changes might not have prevented Everett's tragic death if they were implemented at the time, they were "highlighted as deficiencies in the system" at the time he sadly passed away, she said.
Ms Forbes extended her sympathies to the newborn's family.
She also recommended that the location of placenta positions be better recorded through physical measurements and that O-negative blood be readily available whenever C-sections are performed.
