An expert midwife has told an inquest a baby who lived for just 27 minutes would have survived if his mother had been admitted to hospital sooner.
Archie Batten died following a prolonged labour at home after his mother Rachel Higgs was refused admission to the QEQM hospital in Margate while on the verge of giving birth.
The first-time mum and her partner Andrew Batten, from Broadstairs, had called the hospital but were told the maternity unit was on 'divert' due to a lack of beds.
Instead they were advised to drive the 38 miles to the William Harvey Hospital in Ashford - an hour away.
But almost fully dilated at 9cm, Ms Higgs - who had attended the hospital earlier that day vomiting and in pain and told to come back later - was concerned they wouldn't make it and so community midwives were sent to their home.
Despite enjoying an uncomplicated pregnancy and carrying a healthy little boy, her labour was prolonged and complicated, and the exhausted mum spent five hours trying to push Archie out.
During an inquest at Archbishop's Palace in Maidstone, it was heard 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.
The mum-to-be 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 - more than five hours later - 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".
Speaking at the inquest, midwife Nikki Khan, brought in as an expert witness, on hearing the evidence, said 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, and the baby was stuck and unable to turn.
"These are all indicators that she should have come to hospital early," said Ms Khan.
"The dehydration and malpositioning could have been corrected had she been transferred earlier. Strong Syntocinon (induction drug) could have been administered and Archie would have been delivered quickly.
"Had she come in at 8.30pm and not even necessarily delivered, these issues with dehydration and the positioning could have been corrected and the outcome completely different.
"We have to ask the question why the transfer wasn't requested sooner."
She said basic observations such as testing Ms Higgs' urine with a dipstick, taking blood pressure regularly, monitoring her fluid intake and starting a partogram 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.
Ms Higgs was eventually rushed to hospital where Archie was born, but sadly, despite resuscitation attempts, he died soon after.
His 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.
Assistant coroner Sonia Hayes is due to record her conclusion of the inquest on Tuesday, May 31, almost three years after Archie died.
Timeline of Archie's birth
Ms Higgs and her partner Andrew Batten's ordeal started at 10.30am on September 1, 2019, when the mum-to-be - who had enjoyed an uncomplicated pregnancy and was at full term - had attended the QEQM, suffering contractions and being violently ill.
She was unable to access the labour ward and was examined twice over two hours at the maternity day care centre, but refused admission on the basis she was not in active labour.
She was then told to go home and "wait as long as possible" before returning and said a bed would then be available for her.
But when Ms Higgs called the unit just before 5pm she was again turned away, this time due to the hospital being on 'divert' to Ashford because of a lack of beds.
A midwife was sent to her home and found the mum 9cm dilated and told her to start pushing, at which point Mr Batten excitedly text family members to say the baby was on its way.
Over the next five hours four midwives tended to Ms Higgs, none of whom, according to her solicitor Nick Fairweather from Fairweathers Solicitors LLP, realised labour needed to be progressed and Archie delivered.
It is claimed 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 at 10pm 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.
Baby deaths scandal
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.