Amanda McCall had medical conditions including cardiac disease
A coroner has branded midwife shortages at a hospital where a newborn baby girl died as "nothing short of scandalous".
An inquest heard Ebony McCall's mother, Amanda arrived at Milton Keynes General Hospital in pain and wanted a caesarean section, but was told it was too risky.
Ebony was later born with only a faint heartbeat and she died soon after.
In a narrative verdict, deputy coroner for Milton Keynes Thomas Osborne said "systems failures" and overstretched staff contributed to her death in May.
Mr Osborne said it was "surprising" Miss McCall, from Milton Keynes, was not seen by her consultant until the day before she was admitted to hospital.
He said: "The situation on the labour ward became what has been described to me as 'chaotic' with far too many mums and not enough midwives."
Miss McCall's consultant Anthony Stock had earlier told the inquest: "The care in this case should have been consultant-led.
Amanda's father Terry McCall: "It has had a huge emotional effect on her"
"The care did not come up to a standard that I would have expected normally for a patient booked in my name."
He said Miss McCall, who was 17 at the time and has only one kidney, was considered "low risk" in cardiac terms but when she came into hospital with stomach pain, would have been "high risk".
Miss McCall, now 18, was admitted to hospital on 8 May and went into labour that night but her baby's heartbeat became erratic.
Medical staff said a Caesarean would be too risky and she was advised to have an induced birth to ease her symptoms.
However Miss McCall refused because of the pain she was in and an emergency Caesarean was carried out, the inquest heard.
Ebony, born at 0321 GMT on 9 May, had suffered brain damage due to a lack of oxygen and died 14 minutes later.
Amanda's mother, Breda McCall, told the inquest she sounded the panic alarm when she saw a monitor of the baby's heartbeat spike.
By Nick Triggle BBC Health Reporter
Despite the controversy over maternity standards at Milton Keynes Hospital, the NHS still provides some of the safest care in the world.
There are just 3.2 deaths for every 1,000 lives births, but the overwhelming majority of these are linked to premature birth or physical defects.
The rate is similar to the top-performing European countries, such as Germany and France, and better than many other rich nations, including the US and Italy.
But that is not to say the health service does not have its own problems. Other hospitals, including London's Northwick Park a few years ago, have faced similar criticisms to Milton Keynes.
And while these are obviously some of the worst examples in the health service, there is still one underlying problem which can be found on almost every maternity ward in the country - staff shortages.
Ask most midwives and they will say they are facing too many demands on their time, forcing them to juggle women in labour.
It was only then that her daughter was taken for an emergency Caesarean.
She said she was later told by one of the staff: "If only you had pushed that button five minutes earlier you would have saved your granddaughter."
She said: "I remember these words because I think of them every morning and every night."
Mrs McCall said her daughter's grief was compounded by the fact she was kept on a labour ward for eight days after Ebony's death.
The three-day inquest was told that staff and bed shortages at the hospital had earlier brought criticism.
Last year, Mr Osborne reported the hospital to the Department of Health after the death of baby Romy Feast, who was born by Caesarean section at the hospital in 2007 but died after her cardiotocography (CTG) was misinterpreted.
A Healthcare Commission investigation was launched and Mr Osborne told the hearing the 2008 report found many recommendations had not been met.
The Ebony McCall case has now been referred to the Secretary of State for further investigation.
Speaking after the inquest at Milton Keynes Civic Centre, Amanda's father Terry McCall said: "There seems to be no reason that Ebony died.
"She was born at full term and she was a healthy 7lbs 4oz and, even though she had a slight infection, had the problems been picked up it's likely she would have been with us now, celebrating her first Christmas."
Milton Keynes NHS Foundation Trust's Tony Halton: "We are very sorry indeed"
Criticising midwife shortages at the hospital, Mr Osborne said: "The situation where mothers are left unattended during labour and other mothers are unable to get an epidural is nothing short of scandalous.
"If this situation is allowed to continue the lives of babies and mothers who intend to have their babies at Milton Keynes Hospital will continue to be at risk."
Responding to the verdict, Tony Halton, director of nursing at Milton Keynes Hospital, said: "On behalf of the Trust I would like to offer the McCall family our deepest condolences.
"We are very sorry indeed for the distress and grief caused to them by the death of their daughter Ebony."
He added: "Changes have already been made to the way we work to further improve the safety of our maternity services."
The Care Quality Commission health regulator said the coroner's findings would be used in a follow-up to the 2008 report on the maternity unit.
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