Even more devasting is being told that their death was "avoidable" had it not been for the "complacent" attitude of the hospital's maternity unit.

Heartbroken parents, Justin and Alison Clark, lost their baby boy just four days after his badly-managed birth.

Coroner Sean Cummings said that there had been "group and collective failings", branding staff at Kingston Hospital "complacent" after Sebastian was born with a devastating brain injury due to damage caused during labour.

Sebastian and Alison were both transferred to St George's Hospital but after being told that the baby was brain dead and unable to breathe on his own, the couple took the heart-breaking decision to turn off Sebastian's life support machine.

The coroner is now urging the Royal College of Obstetricians to review whether cervical sweeps after labour starts should be avoided across the UK after hearing about the tragic case.

An inquest heard how Ms Clark, from Surbiton, Surrey, had suffered a spontaneous rupture of her membranes in March 2017, and sought medical advice.

A midwife then performed a cervical stretch and sweep – procedures the trust now accept can heighten the risk of developing infections.

The coroner was told that vaginal sweeps widen the cervix to encourage a natural birth and can "activate" naturally-occurring bacteria such as B Strep and E-Coli in the area.

But Mr Clark said that the pair were told there were no signs of infection and despite asking about having a c-section, were told they didn't need one.

The same day, Mrs Clark had another sweep and by this point, the baby's heart rate was fluctuating and the pair questioned the possibility of having a c-section twice more.

Little Sebastian was eventually delivered by forceps and had suffered catastrophic brain damage.

The coroner said that while he couldn't find systemic failings on the part of the trust, there were "a number of lamentable individual errors" that led up to Sebastian's death.

The baby didn't breathe for 26 minutes after he was born, after staff failed to follow procedure, West London Coroner's Court heard.

He died from multiple organ failure, acute chorioamnionitis and hypoxia – as well as catastrophic brain injury.

The coroner continued: "All the staff members recognised at some point that something was wrong but there was complacency and an assumption that management knew about it.

"The Registrar has admitted it was very busy and she was distracted causing her to lose her helicopter view.

"I am not signalling the registrar out as there was a group and collective failing through the developing emergency until it was too late."

“Sebastian, known as Sebby, is our much loved first born child," said Alison and Justin.

"He was a fiercely strong, 8lb 9oz, auburn, wavy-haired beauty. He continues to provide us with great joy and pride and will forever do so. He has opened us up to a new level of love.

"However, his death has shattered our lives and we will never be the same; part of us will always be with Sebastian wherever he may be.

"Sebastian was a completely healthy little boy up until the point of labour. Ultimately, we feel that a lack of care and treatment led to his death.

"We believe there was an utter failure in fetal monitoring, wellbeing and escalation of care and, if this had not been the case, our son would still be alive today. What happened to him was entirely avoidable.”

The pair are hoping that the inquest will provide further information and insight into their baby's death at the Kingston Hospital Maternity Unit.

In particular, they believe that staff failed to listen to their concerns about having a c-section, and that early delivery would have saved Sebastian's life.

Ms Clark told the inquest that she had initially blamed herself for her baby's death.

For two weeks after the tragedy, she didn't receive a letter from the hospital and had no idea that he had not died from natural causes.

In a letter, a maternity risk nurse apologised for "letting her down".

In a statement released on behalf of Alison and Justin, it said that Kingston Hospital NHS Trust have apologised and admitted that substandard care led to Sebastian’s poor condition at birth and his subsequent death.

Ann Radmore, the Trust’s Chief Executive, wrote to the family on 9 January 2019 almost two years after the events saying: “I would like to offer you my sincere apologies that the treatment and care provided by the Trust immediately prior to and during Sebastian’s delivery fell below a standard that you were entitled to expect.

"We recognise that this substandard care led to Sebastian’s poor condition at birth, and tragically, his death.”

The family's solicitor, Tim Deeming, said: "The heart-breaking loss of Sebastian Clark has left the whole family devastated.

"We now hope this Inquest will ensure the full circumstances surrounding Sebastian’s death are thoroughly investigated.

"We believe that the tragic series of events that unfolded within the Maternity Unit at Kingston Hospital were completely avoidable and we sincerely hope lessons can be learned so no other family has to endure a similarly devastating experience both here and at other units.

"We also believe that there is a wider need for counselling and support at all Hospital’s to support families through any such birth related incidents."

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