A family is seeking civil action against Stoke Mandeville Hospital after their daughter passed away within an hour of her birth.
An inquest found that Molly Daisy Dimmock died of perinatal asphyxia just 34 minutes after she was born.
Senior coroner, Crispin Butler, concluded that an 'underestimation of Molly's fetal weight' and failure to offer a caesarean played a role in the tragedy.
Coroner Butler said: " [A] retrospective review of the 36 week scan by the Health Safety Investigation Branch clinical panel considered that the abdominal circumference of Molly was
under measured and this led to an under estimation of her fetal weight.
"Molly's mother was not referred for obstetric consultation following the 36 week scan. The first opportunity for an obstetric discussion with Molly's parents about the risks of delivery came late in labour, early on the morning of delivery.
"On balance, Molly's parents did not have the understanding that shoulder dystocia was a risk. The option of proceeding straight to a caesarean section was not
offered to Molly's parents and consent was procured on the basis of a trial delivery with Kielland's forceps, only with caesarean section as an option thereafter.
"Molly's body was delivered five minutes thereafter with the umbilical cord wrapped around her neck. Molly was unresponsive, although there was evidence of a heartbeat reported, and, notwithstanding attempts to resuscitate her, she was confirmed to have died 34 minutes after delivery. The risk of shoulder dystocia was heightened by Molly's size."
After the conclusion of Thursday's inquest the family has said they will seek further action against the hospital.
Charlotte and Luke Dimmock lost their first daughter after finding out about the caesarean option too late into the pregnancy and un under estimation of Molly’s fetal weight.
Grandfather to Molly and Charlotte's father, Keith Bateman, told The Bucks Herald: "I'll never forget, receiving the news at 4:15am.
"Luke called me on the phone, sobbing. He said: 'Molly didn't make it'. It was devastating for all the family.
"Luke took it, very very badly. He couldn't talk about it, he still finds it difficult to talk about the entire episode. Talking about Molly is very devastating for both of them.
"One of the difficulties we had was the hospital couldn't even get their facts right when they wrote to Charlotte. They said: 'sorry your child was stillborn', when she never was stillborn.
"We had to go through the painful process of the funeral. [Luke and Charlotte] are weekly visitors to Molly's grave as we all are. To see such a little grave in such a massive burial ground, is still very difficult for us all."
One source of brightness for the family, in what remains a very dark difficult ongoing process is that Charlotte has since delivered another gestational baby.
At a different hospital the baby was successfully delivered using a caesarean section.
Keith said: "By having their second child, it has healed a few wounds. All the stuff in the nursery that was there all ready for Molly when she came home, is at least now being used.
"Ironically enough, the day Molly was born and died, the original pram they bought from John Lewis was damaged and on the day that Molly died John Lewis delivered a brand new pram and took away the damaged one.
"A week or so after I took Charlotte out and we had the conversation 'what do you want to do with the pram?' And she just looked at me and said: 'Dad, we are going to need it.'
"I had to stop the car, I couldn't see where I was going we were both in floods of tears. In a way they were tears of joy. It is difficult to put into words how much it affected all of us. Even my wife's parents who are still with us, they were looking forward to having their first great grandchild.
"It was a mistake that robbed us of that moment."