A newborn baby girl died after doctors ignored her mother's pleas for a C-section which could have saved her life.
Neha Rajesh died 13 hours after she was born by emergency caesarian section and suffered reduced oxygen to the brain and high blood pressure around her lungs on the night of May 7, 2024.
Her mother Divya Rajesh, 34, had begged doctors - who an inquest heard made 'multiple errors' in their care - to perform the procedure hours earlier believing it was the safest way to deliver Neha.
Divya was 35 weeks pregnant when she was admitted to Broomfield Hospital in Chelmsford, Essex, in pre-labour - tests showed Neha had an 'abnormal' heart rate.
But despite the mother and her husband Rajesh, 40, pleading with doctors to carry out a caesarean section, doctors dismissed their concerns and continued to try a natural birth.
Instead - because of a mix-up - Divya was taken from the labour ward on to a day assessment unit, where she was not regularly monitored.
More than four hours later doctors finally delivered her daughter by emergency caesarean but she suffered a hypoxic brain injury and pulmonary hypertension.
An inquest heard medics were guilty of 'multiple errors' before Neha's death, including a 'lack of a plan' and an absence of 'holistic care'.
Rajesh holding his daughter Neha after her care was withdrawn and shortly before she died
Divya and Rajesh, pictured with their four-year-old daughter Saatvika, said the two years since Neha's death had been 'the most painful and difficult time of our lives'
Essex coroner Sonia Hayes said if Neha had been delivered earlier her life would have been 'prolonged' and the hypertension could 'probably' have been avoided.
The couple have hired medical negligence solicitors to investigate the hospital and said the last two years had been 'the most painful and difficult time of our lives'.
Rajesh said: 'As parents we tried to explain our concerns and how worried we were about our baby. However, it often felt as though our voices were not heard.
'We trusted the hospital and believed that our baby was in safe hands. Learning that there were points where different decisions or actions might have changed the outcome leaves us with deep sadness, frustration and heartbreak.'
He said losing their daughter had left 'a deep and permanent void in our family'.
'Every day we think about the life she should have had and the memories we will never get to create with her,' he said.
'Instead of watching her grow, we are living with grief and the constant thought that things might have been different if our concerns had been taken seriously.'
The couple, who also have a four-year-old daughter, Saatvika, have said guidelines on caring for women in labour should be improved.
Rajesh added: 'Much of the past two years has been spent trying to understand what went wrong and why our worries as parents were not properly heard when we repeatedly sought help.'
The couple said Divya was referred as an emergency patient to the hospital but it still took over four hours for a caesarean section to be ordered.
Neha was also not intubated for more than two hours after her birth despite having problems taking in oxygen.
Medics finally recommended a caesarean at 5pm but Neha was not delivered until 10.56pm.
After she was born Neha was resuscitated but not intubated until nurses raised concerns on the Neonatal Intensive Care Unit (NICU).
Doctors later withdrew her care and she died after midday on May 8 in Rajesh's arms.
The father said he and his wife were haunted by the failure of care in hospital.
He said: 'We were concerned about our baby and wanted to make sure everything was safe - but despite being in the hospital and raising our concerns, we felt that the seriousness of the situation was not recognised.
'Instead of feeling supported, we often felt that our worries were dismissed, almost as if we were worrying for no reason.
'We trusted the medical professionals and believed that they would carefully assess the situation and act if something was not right. Looking back now, it feels like there were several opportunities where further checks or earlier action could have been taken.
'We believe that parents' voices must be properly listened to. When parents repeatedly say that something does not feel right, those concerns should never be dismissed.
'Our hope is that by understanding what happened in Neha's case, lessons will be learned so that no other family has to go through the devastating loss that we have experienced.'
Neha's parents begged doctors to deliver her by caesarean section hours before they took action
Mid and South Essex NHS Foundation Trust admitted Neha should have been delivered earlier.
The couple's solicitor Emily Welstead said: 'Divya and Rajesh have suffered the most unimaginable loss and are understandably traumatised by the way they lost their precious daughter.
'To know things could have been so different had they received the care and compassion they were entitled to expect is absolutely heartbreaking.'
Christine Blanshard, Chief Medical Officer for Mid and South Essex NHS Foundation Trust, said: 'We offer our sincere condolences to Neha's family.
'Shortly after Neha's death we carried out an investigation and found areas where the care of her and her mother could have been better.
'This included listening properly to the parents' concerns, more observations, better handover between shifts and closer monitoring.
'We have taken learning from this sad death and are working with our obstetric teams to improve monitoring and ensuring more detailed clinical handovers between teams.'