Hospital chiefs have apologised to the parents of a baby boy who died while under their care and admitted that standards "fell short" before his death.
Little Harry Richford was born at the QEQM Hospital in Margate on November 2, 2017, after a traumatic and long labour in which his heart rate frequently dropped.
He was eventually born by emergency caesarean but was so unwell had to be transferred to the neonatal intensive care unit at the William Harvey Hospital in Ashford.
After just seven days, Harry died of hypoxia, a condition caused by lack of oxygen, leaving his parents Tom and Sarah, from Birchington, devastated.
Today, as the inquest into his death started, East Kent Hospitals Trust, which runs the QEQM, issued a statement apologising "wholeheartedly" to the couple.
"We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to his family," a spokesman said.
"We accept that Harry’s care fell short of the standard that we expect to offer every mother giving birth in our hospital.
'We apologise wholeheartedly for their devastating loss' - East Kent Hospitals Trust
"We have thoroughly investigated the circumstances of Harry’s birth and care, and we have made a number of significant changes to our maternity service as a result of this investigation and welcome any further recommendations from the coroner.
"We hope the inquest gives Harry’s family the answers they need and we apologise wholeheartedly for their devastating loss."
The full inquest into his death, expected to last two weeks, started today with the couple's legal team calling on witnesses, including three midwives and a registrar who were on shift during Mrs Richford's difficult labour.
Questioning took place about the monitoring of Harry's heartbeat through cardiotocographs (CTG), the back-to-back position of the baby during labour and whether Mrs Richford had the dangerous condition uterine hyperstimulation while being given the drug Syntocinon, used to help progress labour.
During proceedings, led by coroner Christopher Sutton-Mattocks, it was also heard how staff disagreed over whether Syntocinon should be administered while the baby's heart rate kept dropping.
Midwife Susan Barnes told the court that when Mrs Richford was transferred from the midwife-led unit, which is for low-risk mothers, to the labour ward, for high risk patients, a CTG was in place monitoring Harry's heart.
The mum-to-be had been in the early stages of labour for a considerable time, but was not progressing into established labour, which begins when the cervix is dilated four centimetres.
Mrs Barnes said: "When I took over care, there was one episode of deceleration in the baby's heart and we decided that if it continued to be 'non-reassuring' we would tell the doctors.
"The heart rate dropped down, went back up again, then dropped down indicating a problem."
The registrar on duty was in theatre but made aware of the situation and directed staff to begin Syntocinon infusions to progress labour.
But Mrs Barnes and a senior midwife held off, fearing it not to be safe, until Harry's heart rate was normal.
During the hearing, Mrs Barnes was questioned over staff training of CGT monitoring and she said there had been further training last year which was "much more helpful and specific" than previously.
She admitted that had it been in place ahead of the Richford case, things may have been looked at differently.
Registrar Dr Aderwale Ogunyanwo was also called as a witness and cross-examined by Mr and Mrs Richford's legal team about whether the mum had uterine hyperstimulation.
He said the condition is when a pregnant woman is having six or more contractions within 10 minutes - or five and other complications - which is dangerous to the baby.
But when asked by Jennifer Macleod, of Brick Court Chambers, if Mrs Richford was suffering this due to the high number of contractions she was having, he replied that he didn't think so.
Ms Macleod said: "We've got a woman with five, sometimes six, contractions in 10 minutes and a large deceleration in the baby's heart rate - as I would see it this is abnormal."
But the registrar insisted this not to be the case.
"In the overall context it is normal because the CTG was showing there were accelerations (in the heart rate) which was a reassuring sign," he said.
In the next two weeks, more staff, including the doctor who delivered Harry, will give evidence.
The inquest continues until January 21.