A baby died aged just four days old after a “lamentable number of individual failings” by hospital staff, a coroner has ruled.

Sebastian Clark was born brain dead and not breathing at Kingston Hospital on March 8, 2017, despite a completely healthy pregnancy, after his mother developed an infection during labour.

Although he was resuscitated and moved to St George’s Hospital in Tooting for emergency care, he was unresponsive to light and sound, the outer cortex of his brain was entirely damaged and there was no chance of recovery.

His parents made the heart-breaking decision to turn off his life support machine on March 12, and he died in their arms four hours later.

On January 17, after a two-day inquest at West London Coroner’s Court, heartbroken parents Alison and Justin heard the coroner outline just how avoidable the death of their son was.

HM Coroner Dr Sean Cummings said: “There were sequential and individual errors, both in terms of assessing the information and communicating it to colleagues.”

Although there were no systemic errors by Kingston Hospital – “adequately set up” procedures were in place – there was “a lamentable number of individual failings”.

The hospital trust accepted that a cervical stretch and sweep should not have been performed while labour was underway – as this was a likely cause of Mrs Clark developing chorioamnionitis, the infection that put her baby at risk.

Dr Cummings added: “There was inadequate leadership in terms of managing Mrs Clark’s condition and the effect on her baby.

“There was complacency in managing and defining the situation with the assumption that others on the ward knew about it.”

Dr Cummings said the labour ward was “exceptionally busy”, with other emergency cases taking up medical staff’s time.

He said the registrar, Dr Kohler-Boureq, had become distracted by these other cases, causing her to “lose her helicopter view” of the ward – meaning Mrs Clark was not given enough of her attention.

“This is not to single her out,” Dr Cummings stressed. “There was a group and collective failure to appreciate the developing emergency until it was too late.”

Although Mrs Clark’s condition was being monitored, the effect on baby Sebastian went “unrecognised”.

Speaking after the inquest, Tim Deeming of Tees Law, representing the family, said: “While Justin and Alison are relieved that the inquest is over, they are understandably devastated as his death has shattered their lives.

“Sebby was a completely healthy little boy up until the delivery and the multiple failings, complacent management and lack of fundamental care caused his death.

“It was entirely avoidable and as the Coroner heard today the hospital did not intervene early enough.”

Earlier in the day, the inquest heard Sebastian was allowed to go “over the cliff” during the labour – with medical staff not bringing forward the birth (by performing a caesarean section, for example) when they could have.

Miss Diana Fleming, a consultant obstetrician and gynaecologist at the hospital who was involved in writing a report about the case, said Sebastian was coping with the infection, but in the end he could no longer compensate against the stress of labour, and his body gave in.

She said: “We missed the cliff edge, but it’s not black and white where that cliff is.”

Miss Fleming admitted, though, that she would not have done anything different if she had been caring for Sebastian.

She said: “I would have said wait. That’s a tough thing to say, because I know what happened.”

Asked what the last time Sebastian could have been saved was, she replied: “I don’t know. But we could have intervened before that.”

Dr Cummings will now ask the Royal College of Obstetricians and Gynaecologists for their views on rolling out new guidelines that Kingston Hospital has adopted nationally

He will also raise the prospect of screening women for Group B Streptococcus – bacteria present in about 20 per cent of women that could have caused Mrs Clark’s infection.