An inquest has returned a verdict of medical misadventure after the stillbirth of a baby girl at Our Lady of Lourdes Hospital in Drogheda over three years ago.
Willow Clarke, who was full term, was delivered stillborn on 15 August 2018.
Her mother, Pamela Clarke, who had gestational diabetes and was deemed high risk, was admitted to hospital the morning before to begin the induction process.
But the inquest heard that while CTG tracings of the baby's heartbeat were carried out, issues around how guidelines surrounding the management of a pregnant woman with gestational diabetes arose.
The hearing was told there were staffing issues on the maternity ward with just two instead of three midwives on duty.
Returning a verdict of medical misadventure, Coroner Ronan Maguire said it was clear that hospital guidelines surrounding the care of a pregnant woman with gestational diabetes were "ambiguous and confusing" and were not adhered to by staff.
Pamela Clarke was high risk and she should have been monitored more carefully and more frequently, he said.
The coroner added that no warnings were given to Ms Clarke about the risk associated with the propess medication, which had been given to her to open her cervix, as part of the induction process.
He also noted that from evidence given by midwives working that night, the maternity ward was "understaffed and overworked" with two midwives looking after 22 patients.
At the end of the inquest the hospital said it wanted to acknowledge the profound affect the death of Willow has had and apologised again for the deficit in care.
Earlier, Pamela Clarke told the hearing that she is heartbroken since her baby's death.
"The moment I heard them say I'm sorry there is no heartbeat my whole world as I knew it completely fell apart.
"I will never know the colour of her eyes, I will never get to hear her voice, see her walk or run. I've lost out on seeing her get her first tooth, her first day at preschool which should have been this year, her first day at national school," she said.
"How could a normal pregnancy end with me having to say goodnight to my daughter in a cold, dark graveyard instead of her warm, cosy cot.
"It’s been a long, painful three years to wait to get answers to why our baby Willow lost her life," she added.
