The parents of a baby who died shortly after he was born at Altnagelvin Hospital in Londonderry have said lessons must be learned from his death.
Three-week-old Kyle Parke was one of four babies who died in the hospital during a six-week period in 2006.
On Monday, the chief coroner said staff did not carry out an immediate Caesarian section as they didn't spot a problem with the baby's heart rate.
Kyle's mother, Shirley McClean, said staff need more training.
"You think you go into hospital and you have a baby, everything will be okay and you are in good hands and that they know what they are doing more than you would know," she said.
"But to think that four babies died due to something that staff were lacking in training in... it shows that they are obviously not training the staff properly in this area."
At an inquest on Monday, Chief Coroner John Leckey called for more training for staff monitoring babies during labour.
He is to raise the matter with Northern Ireland's chief medical officer.
Mr Leckey said that the problem was not limited to Altnagelvin Hospital.
He said medical and nursing staff in all hospital labour wards should constantly be trained in how to interpret the results of cardiotocograph traces, which monitor heartbeats of children in the womb.
In a statement, the Western Trust said they fully accepted the Coroner's findings and they have fully implemented the recommendations made.
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