Parents paid 'biggest price' for maternity unit failures
Kimberly and Gary Stewart said more should have been done to save their daughter, Nevaeh.
The heartbroken parents of a newborn baby who died at a community maternity unit in Angus say it is vital lessons are learned.
Earlier this month a Fatal Accident Inquiry ruled the failure to provide an emergency ambulance contributed to Nevaeh Stewart's death in 2012.
And Kimberly and Gary Stewart believe more could have been done to save their daughter.
Mr Stewart said: "NHS Tayside were of the opinion that the community midwifery units were unacceptable emergency response blackspots because that is exactly what they were.
"They were content to allow for the possibility of not being able to attend these units at all but a home birth would get a 999 response."
The family now want parents to be given information about the risks of having a water birth at a midwife unit.
Mr Stewart added: "It is a life and death decision which you are making - which we did make - but we did not have the information to make the decision and tragically we have paid the biggest price you can for that."
Since Nevaeh's death NHS Tayside have introduced videolinks to midwife units allowing specialists to see babies sooner and, crucially, midwives now have the option to call 999.
Mrs Stewart fought back tears as she recalled the day she lost Nevaeh
She said: "I feel that the time we spent with her after she died holds more special memories that the time she was actually alive.
"She fought for just shy of two hours and she should have received that specialist care far sooner than she did."
A Sheriff ruled Nevaeh's death could have been prevented if an emergency ambulance had been made available to rush her to hospital when she took ill.
Nevaeh died three-and-a-half hours after she was born at Montrose Royal Infirmary's community midwifery unit on 29 September 2012, despite the efforts of midwives based there and specialists who rushed from Dundee to her aid.
A sheriff ruled that Nevaeh had "simply languished" at the midwifery unit receiving only "basic resuscitation" because NHS guidelines wouldn't allow a blue light ambulance to be sent to collect her.
The dedicated neonatal team that was allocated to cover Montrose at the time was on another job in Wick when she was born.
If Nevaeh had been a home birth and not born in the midwifery unit a blue light 999 ambulance would have been sent to pick her up.
The inquiry at Forfar Sheriff Court - which lasted 14 days and heard from 16 expert witnesses - heard Nevaeh was born in a birthing pool at the Angus facility, but was immediately found to be "pale and floppy".
An ambulance from Ninewells Hospital took almost two hours to arrive - leading to accusations the standard of care given was "contributory to her death".