A baby boy died after maternity staff failed to monitor his condition several times, an inquest heard.
Giles Cooper-Hall was only 16 hours old when he passed away at Derriford Hospital in Plymouth in October 2021, the inquest in Plymouth heard.
His parents Allison and Ruth Cooper-Hall from Plymouth are now calling for a national public inquiry into maternity safety.
The hospital said it recognised there were missed opportunities.
The inquest heard that Giles was born after a routine pregnancy, with no cause for concern until his mother Ruth reported reduced movements at 41 weeks.
During labour it became apparent that the baby's heart rate was fluctuating, and Giles was born showing no signs of life.
He was resuscitated after 20 minutes, but Giles had a severe brain injury among other challenges and died that evening.
The Healthcare Safety Investigation Branch (HSIB) found that the staff failed to follow the care plan for his mother's labour.
They did not check her baby's heartbeat regularly, measure her baby bump, or seek help from senior doctors when there was an emergency.
Assistant coroner Louise Wiltshire said that Giles's death could have been avoided if the staff had acted differently.
She noted several missed opportunities to help Giles, including clinicians failing to review maternity notes so information was not passed on, and a care plan set out by a senior consultant was not followed.
She recorded a narrative conclusion stating Giles died from a brain injury caused by a lack of oxygen, and said that this was a "truly tragic case".
Giles's parents Allison and Ruth said in a statement after the inquest: "The hopes and dreams we had on the birth of our son Giles have been completely shattered."
They said a "catalogue of systemic problems and issues" had "led to the tragic death of our baby boy".
They said: "This is not the first time something like this has happened and sadly unless more steps are taken it will not be the last."
Sue Wilkins, the hospital trust's director of maternity services, re-expressed the trust's condolences to the couple.
"To sit and listen to Giles's short journey in life, I can't begin to think what this has been like for them," she said.
She said the trust had put all of the HSIB's recommendations in place.
"We agree totally, there were missed opportunities and for that we deeply express our apologies," she said.
She added: "I think we could never say that missed opportunities wouldn't happen but I am confident that we have put everything in place we possibly could in our learning from the sad loss of baby Giles."