Wayne and Karen Coyne: Anger at report
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Two midwives at the Royal Cornwall Hospital were out getting a take away while a baby fought for her life.
The BBC has obtained a copy of the independent review panel's report into Caitlin Coyne's death.
It highlights a number of failings in the care of Caitlin and her mother Karen on Christmas Eve last year.
The baby girl was born by emergency Caesarean section but died the next day. Caitlin's father Wayne has said he is furious.
He said: "To find out that the midwife who was looking after Karen and Caitlin that evening was calling for help while two other widwives were out ordering a Chinese meal belittles my daughter's memory.
"But the professionals in charge of that unit allowed it to happen."
Training call
Twenty-four recommendations are made in the report.
They include making sure that staffing levels are adequate and procedures are in place when a woman with obstetric problems is due.
It says communication skills need to be honed and the training of staff in cardiotocography (CTG) equipment should continue.
Brian Milstead, chief executive of the Royal Cornwall Hospital's Trust, says in a letter to Mr and Mrs Coyne: "I would like to offer my sincere condolences on your sad loss and to personally apologise for the shortcomings in care that have been identified, and for the distress and pain this has caused. "