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A coroner has published 19 recommedations for improvements at East Kent Hospitals maternity units following the "wholly avoidable" death of baby Harry Richford.
Christopher Sutton-Mattocks last month ruled after a three-week inquest that the baby boy, whose parents Tom and Sarah are from Birchington, was "failed by the hospital".
Harry was born at the QEQM on November 2, 2017, after a long labour and chaotic delivery by emergency caesarean, performed by an inexperienced locum.
When he was eventually delivered, it took medics almost half an hour to resuscitate him, leaving him so unwell he had to be transferred to the neonatal intensive care unit at the William Harvey Hospital in Ashford.
Mr Sutton-Mattocks said had it not been for the failings of the hospital, he would have lived and not had brain damage.
In a Regulation 28 report published in full today, he sets out 19 recommendations for improvements focusing on the recruitment, assessment, supervision and record-keeping relating to locums, with an emphasis on the "permitted scope" of locums' activities before they are left responsible for out of hours care of women in labour.
He also recommends a review of procedures relating to consultant attendance, technological solutions to help access on-call consultants, regular training in neo-natal resuscitation, to review the provision of cross-site paediatric working and to ensure staff are aware of policies.
The report also outlines the need for a review of obstetric and paediatric staff's awareness of guidance, for improved record-keeping and to ensure statements are made by staff in the event of serious incidents.
Mr Sutton-Mattocks also recommends the trust consider a review of its policies so that all staff members who fill in Child Death Notification forms are aware of what to enter into the form and of the details required and all such forms should be logged and audited, including those since Harry's death.
He also recommends a review of all MBRRACE forms filled in since Harry's death were accurately completed and reported.
After Harry's death, the forms were filled out incorrectly, with his death described as "expected".
Finally, the coroner says the trust should consider a review of its policies in respect of the sharing of important investigations among all relevant staff so that learning takes place to prevent any future deaths.
A spokesman for East Kent Hospitals said improvements are being made at the trust.
"We are taking all necessary steps to provide safe care and we are treating the recently raised concerns about the safety of our service with the utmost seriousness and urgency."
Earlier today the CQC raised concerns about the maternity units at the trust.
A review into 26 maternity cases at the trust, including several deaths, is ongoing.
