A newborn baby who lived for just 27 minutes would have survived if his mum had been admitted to hospital sooner and not turned away twice from the nearest one.
A coroner found that neglect contributed to the death of Archie Batten, who died after a prolonged labour at home, with a string of missed opportunities leading to complications.
His mother Rachel Higgs had twice been refused admission to hospital while on the verge of giving birth, an inquest heard.
She was eventually rushed to hospital, but the complications meant Archie only managed to breathe independently for a short time and died after attempts to resuscitate him failed.
An inquest heard that first-time mum Higgs had visited the Queen Elizabeth the Queen Mother (QEQM) hospital in Margate, Kent, as she was about to give birth in September 2019 but was refused admission on the basis she was not in active labour.
She was told to go home and "wait as long as possible" before returning, when a bed would then be available. But later when she and her partner Andrew Batten returned - by which point she was almost fully dilated - they were again turned away, this time due to a lack of beds, and told to drive 38 miles to hospital in Ashford, Kent.
Rather than make the hour-long trip while on the verge of giving birth, community midwives were sent to their home, where Higgs spent five hours trying to push Archie out during a prolonged and complicated labour.
The inquest heard that she became dehydrated and her baby became stuck and unable to turn, but none of the midwives realised she and Archie were in danger.
An ambulance was eventually called once the severity of the situation was realised by one of the midwives, but by that point it was too late and Archie lived just 27 minutes.
Concluding the inquest in Maidstone, Kent, on Friday, coroner Sonia Hayes said there was a number of missed opportunities which led to complications in labour.
She said: "I find there were multiple missed opportunities to render care to Rachel and as a consequence to Archie, that were obvious and not only would have made a difference but would have prevented the death of Archie.
"Failures amounted to gross failures to provide basic medical treatment. There were a number of missed opportunities to avoid the prolonged labour."
She said there were failures in communication and nobody had spoken to Higgs about what she wanted.
Archie's medical cause of death was recorded earlier in the nine-day inquest as being due to a perinatal hypoxic-ischemic brain injury caused by prolonged labour.
Concluding the inquest, the coroner ruled that Archie would have survived and been born without neurological defects if he had been admitted to hospital.
Giving evidence during the inquest, midwife Nikki Khan said issues during Archie's labour could have been "corrected" and the outcome "completely different".
She said basic observations hadn't been carried out, and there had been several indicators that she should have gone to hospital early.
Watch: Families criticise review into baby deaths
In August 2020, almost a year after his death, East Kent Hospitals Trust admitted its care was substandard and Archie would have survived without any kind of injury had he been delivered earlier.
In a statement, Archie's parents said: "It seems incredible to us that so many basic mistakes were made by so many people
"Archie would be two and a half years old now. We think about him and miss him everyday and always will.
"Nothing can bring him back to us, we can only hope that true lessons will be learned from this case and lasting changes made to ensure other families do not suffer such tragedies in the future."
Tracey Fletcher, Chief Executive of East Kent Hospitals, apologised unreservedly on behalf of the Trust, saying: "We fully accept the Coroner’s findings and conclusion today and we are deeply sorry for the failings in the care provided to Archie and his family in September 2019.
"We have made - and continue to make – changes and improvements to the quality and safety of our maternity service.
"Since Archie’s death, we have made changes to how we care for women and babies during a homebirth; and to how we provide the service when the hospital maternity units are busy.
"The lessons from Archie’s death, and the findings of the independent investigation into our maternity service being led by Dr Bill Kirkup, will be built into our continued improvement, to ensure we provide high-quality maternity care for families in East Kent."
Archie's death was one of a number of potentially avoidable baby deaths at East Kent Hospitals, which is currently subject to the Kirkup Review, an independent inquiry looking at its performance since 2009.
In other areas of the country, concerns have been raised over maternity services and issues with baby deaths.