Kate Stanton-Davies death: Midwives' failings highlighted
Two midwives should be referred to their regulator over the care of a baby who died six hours after her birth, an investigation has found.
The review into the care of Kate Stanton-Davies found "serious concerns" about their fitness to practise.
Kate 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 said it accepted the report's findings.
NHS England commissioned the External Midwifery Supervisory Review following years of campaigning by Kate's parents.
The baby, who had anaemia, was born "pale and floppy" and died after being taken by air ambulance to Birmingham's Heartlands Hospital
The report concluded her death was avoidable.
After the birth, Kate's mother Rhiannon Davies collapsed from blood loss and was taken to hospital in Worcester.
Repeated signs the pregnancy was not low-risk were not picked up, the review found.
It has been recommended the two midwives be referred to the Nursing and Midwifery Council.
One failed to "consistently assess" the baby's wellbeing during the pregnancy, including considering reduced foetal movements reported by Ms Davies on three occasions.
Meanwhile, the second midwife failed to recognise Kate's poor condition at birth and could not provide assurances she could "competently" recognise a baby's deterioration or an urgent transfer situation.
Both also failed to maintain clinical records, it said.
The report recommended a third midwife should be supervised and a fourth receive developmental support.
The inquiry found systemic and cultural failings with poor standards of documentation at Shrewsbury and Telford Hospital Trust.
It also concluded emergency procedures at the Ludlow unit were unclear.
Simon Wright, the trust's chief executive, said: "We recognise that the care provided for Rhiannon and her daughter in 2009 failed to meet the high standards we set for all of our patients and that the trust's complaint handling process fell short of what is expected."
The trust is reviewing other deaths from the period to ensure there were "no wider cultural problems in 2009".