A coroner has criticised the skills of midwives who he said could have saved the life of a newborn baby boy if they had acted earlier.
John Leckey yesterday highlighted the importance of refresher courses for midwives across Northern Ireland following the death of Paul Samuel O'Neill on November 9, 2005.
Paul was born in Antrim Area Hospital "in poor condition" with the umbilical cord wrapped three times around his neck. Attempts to resuscitate him were unsuccessful.
He was transferred to the Neonatal Unit, but died four days later from Ischaemic brain injury.
However in his findings following an inquest into the baby's death, Mr Leckey said if the midwives had contacted a doctor earlier during the labour it would have improved the chances of baby Paul surviving.
The inquest revealed that during labour the midwives failed to spot a drop in the baby's heart rate through the cardiotocograph (CTG). His mother Olivia Bell, (30), from Antrim, had suffered from mild pre-eclampsia and had been induced.
In independent reports carried out by medical experts, Ms Bell was labelled as being of both "high and moderate risk".
Professor William Thompson from Queen's University, Belfast, and Pauline Treanor, director of Midwifery and Nursing at Rotunda Hospital, Dublin, criticised the actions of the midwives.
Ms Treanor added that the changeover of staff "at a crucial stage of labour" may have contributed to not spotting the abnormal fetal heart tracings.
Professor Thompson said there was evidence that the fetal heart rate was " pathological" as defined by NICE guidelines.
He said these problems "were not identified by the staff who supervised the labour".
Ms Treanor said there were a number of "suspicious patterns" on the cardiotocograph (CTC) which should have led to a doctor being contacted for advice.
Prof Thompson said sometimes an electrode may be attached to the baby's scalp for more accurate monitoring of heartbeat.
An internal hospital review also said the midwives failed to interpret the CTG tracing accurately or take appropriate action.
Mr Leckey said: "By 1am the readings would have justified the midwifery staff contacting the doctor on call and by 1.20am at the latest the decelerations and the poor quality of the recordings should have been reported to the doctor on call by the midwife supervising the labour. This did not happen."
However, giving evidence, Heather McComish, a midwife since 1984, said at no stage did she consider either the need for a fetal scalp electrode or contacting the doctor on call.
She said she was familiar with NICE guidelines on fetal heart monitoring but not aware if they were introduced in the hospital.
A witness statement by midwife Evelyn McFadden, who said she helped monitor Ms Bell during tea breaks, was also read out.
Mr Leckey said: "If fetal heart traces had been interpreted correctly and medical assistance sought promptly, opportunities existed for the earlier delivery of the baby... Earlier intervention would have improved the chances of survival."
Pre-eclampsia and intrapartum hypoxia related to Umbilical Cord Entanglement were also named as contributing causes of death.
Mr Leckey passed on his "sincere condolences" to both Ms Bell and her partner Paul O'Neill senior and also highlighted the importance of refresher training courses for midwives in Northern Ireland.
A solicitor for the hospital said "substantial steps" have been taken since the tragedy to address the training issue at the hospital.
Paul's family, including Paul O'Neill senior, and Ms Bell said: "The death of baby Paul in these circumstances in the 21st century is nearly beyond belief.
"We reiterate that no other baby should die or family suffer as baby Paul's has."