One midwife said: ‘You’ll laugh about this when you’re older’

shortages. And an internal report linked staff shortages to a series of deaths, although this did not include Dominic.

The document exposed shameful lapses in maternity care at the Royal Oldham and North Manchester General.

In it, maternity director Deborah Carter wrote: “The effect of poor staffing numbers in clinics has meant women have fragmented care, suffered long waits and not had appropriate management.”

And a coroner again ruled the Oldham hospital’s neglect had contributed to a baby’s death. Premature, nine-day-old Daniel Grogan died in November 2016 from an infection after medics failed to give him antibiotics.

In January, new figures revealed that

more than £84million has been paid out in damages for mistakes made by the hospital trust which runs the Royal Oldham since 2012.

Childbirth charity NCT suggested last December that maternity care in England was “in crisis”.

A report found that a total of 276,767 maternity mistakes were logged between April 2015 and 2017 – the equivalent of one for every five births.

While most were minor or near misses, the figures released by NHS Improvement included 288 cases in which mother or baby died. This includes Chelsea’s case, which could have been avoided if overworked staff had not made simple mistakes. The Pennine Acute Hospitals NHS Trust, which ran the Oldham hospital, merged with the Salford Royal NHS Foundation to become the Northern Care Alliance NHS Group last year. Simon Mehigan, Group Director of Midwifery and Gynaecology, said: “We would like to express our sympathy to baby Dominic Smith’s parents, family and friends for their loss and apologise to his mum Chelsea for the mental anguish she has experienced since losing her son.

“We have carried out a thorough investigation into the circumstances surrounding Dominic’s death at The Royal Oldham Hospital on 2 June 2015.

“We are sad to say that he did not receive the high standard of care we usually provide, and for that we are sorry.

“We have introduced a number of improvements to prevent these failings from occurring again.

“Since 2015, we have strengthened and put in place new leadership teams across our hospitals with greater focus on service improvements and learning from incidents.”