Following an internal investigation, Maidstone and Tunbridge Wells NHS Trust acknowledged it must listen to mothers and apologised for using language that made Elena feel like her baby’s death was her fault. 

“This was not the intention of the midwife, who apologises for the distress this caused and has reflected on your comments to inform her practice in the future,” said Miles Scott, the Trust’s chief executive, in a letter to Ms Sala.

Asked why the “doctors and midwives were bickering the whole time”, he added: “I am very sorry that it appeared that staff were in disagreement, as this was not the case.

“The midwives felt that you needed to go to theatre for more pain relief and expressed this to the doctor, who was proceeding with an attempted forceps delivery.

“I acknowledge that this was a stressful time for you and apologise that these discussions contributed to this.”

The internal investigation followed a report by the Healthcare Safety Investigation Branch (HSIB) which found there was a failure to escalate monitoring after Elena made clear she had strong urges to push.

There was also a failure to recognise the Cardiotocography (CTG) trace was abnormal following a long deceleration, and a failure to urgently escalate Ms Sala’s case to a senior obstetrician after her pulse was found to be 130 beats per minute.

The report also suggested that when Ms Sala’s temperature spiked during labour, she should have been treated with a “bundle” of medical therapies known as the “Sepsis 6”.

‘I was just made to feel like it was all my fault’

Ms Sala, from Maidstone, said: “It was horrific from the beginning to the end – like something out of a horror film. 

“There didn’t seem to be any rush, even though it was clear the baby was struggling. All I can remember is the midwives and doctor bickering between themselves.

“I had to wait two hours for an epidural and when it came, it didn’t work. I was in agony and no one seemed to believe me. I was simply told to calm down and that I was stressing the baby out.

“I will always regret not holding Rosanna more for the few days she was alive, but I was just made to feel like it was all my fault. 

“It was just horrendous. I wouldn’t want what happened to me to happen to anyone else.”

Ms Sala has since given birth to another daughter, Lola, who is five weeks old.

‘Midwife exodus’

Earlier this month, the Royal College of Midwives warned of a “midwife exodus”, after over half (57 per cent) of its members polled in its latest survey said they were considering leaving the sector in the next 12 months as coronavirus-related burnout exacerbates long-term staff shortages.

Mark Bowman, from Fieldfisher, is representing Rosanna’s parents at this Thursday’s inquest into her death and investigating potential negligence by the hospital trust. 

He said: “At the exact time an expectant mother is at her most vulnerable, it is crucial she is shown the respect and compassion she deserves and receives the treatment any of us would expect. 

“Review of the records plus the independent HSIB report of Rosanna’s case seriously question whether this was true for Elena. We will explore matters further once the inquest concludes.”

A spokesman for Maidstone and Tunbridge Wells NHS Trust declined to comment.