The parents of a baby girl who died hours after being born breech were falsely reassured that "everything was fine", her father has told a fatal accident inquiry.
Eckhardt Bosch told the inquiry at Glasgow Sheriff Court that "systemic failures" led to the death of his otherwise healthy daughter, Mirabelle, in July 2021.
Mr Bosch and his wife Rozelle, both originally from South Africa, were giving evidence on the first day of a long-awaited FAI into the deaths of three infants in Lanarkshire between 2019 and 2021 which the Crown Office has said gave rise to "serious public concern".
Mirabelle was just 12 hours old when she died at Wishaw General hospital following a "traumatic" birth which had ended in her mother being rushed to hospital by ambulance.
The inquiry will also examine the circumstances surrounding the deaths of Ellie McCormick, who was five hours old when she died at Wishaw General on March 5 2019, and Leo Lamont who was two hours old at the time of his death at University Hospital Monklands in Coatbridge on February 15 2019.
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Mr Bosch said the failure to diagnose that his daughter was in the breech position - where babies are delivered bottom-first rather than head-first - had led to her death.
Although breech babies can be delivered safely, it increases the risk that they may choke on the umbilical cord.
In most cases, expectant mothers will be offered an elective caesarean or a procedure to reposition the baby prior to birth.
Mr Bosch said: "My daughter Mirabelle Bosch was an undiagnosed breech baby.
"The prenatal examination procedures were unable to diagnose the position of Mirabelle correctly - the consequence was that misguided and incorrect instructions were given to me and my wife."
He added: "The pre-natal examination before the death of Mirabelle gave us the impression that all was going to plan and that there was no need for concern.
"We were very much at ease...there were no red lights, no concerns, nothing. We were led into a dark tunnel.
"We were under the impression that the whole pregnancy was smooth sailing...the information we were given put us at ease: 'everything will be fine' still rings in my ears."
The couple, who live in a rural part of Lanarkshire, had been looking forward to welcoming their first child in the summer of 2021.
The inquiry heard that a routine physical examination at an antenatal appointment on May 13 2021, when Mrs Bosch was 31 weeks pregnant, found that Mirabelle was in a cephalic position - meaning head-down.
However, an ultrasound on May 14 suggested she was in breech.
Giving evidence to the inquiry, Lesley Nichol - Mrs Bosch's appointed midwife - said this was not a cause for concern as "babies can move all the time until they're born".
Subsequent physical examinations at 34 and 37 weeks concluded that Mirabelle was cephalic again, before she was born breech at 38 weeks.
Ms Nichol conceded that it was "always possible" that Mirabelle had never moved out of the breech position after the 31-week scan.
Mrs Bosch, 34, told the inquiry how she had attended maternity triage at Wishaw General after her waters broke on June 30 2021, but was later discharged following "basic checks" with an appointment to return to be induced at 9am on July 2 if her labour had not progressed.
She said she became increasingly anxious about the pattern of her contractions which went from "irregular, infrequent then regular, frequent" with the pain "coming and going".
Mrs Bosch said she contacted Ms Nichol and the maternity ward five times with concerns, but said she was advised to wait until contractions were coming regularly three to four times in 10 minutes.
"By then I had been in labour for what I was thinking was 18 hours," said Mrs Bosch, adding: "This is the tragedy - if I had known [Mirabelle] was breech, I would have been very proactive."
An ambulance was called to the couple's home, but Mr Bosch said the paramedics appeared "incapable and incompetent to deal with this situation".
He added: "I still feel the trauma in my body if I think of how they moved my wife to the hospital - it's more than wrong.
"A mother in that condition to move her in that way, it's more than wrong.
"I would like to make the court aware of the absolutely disastrous way they moved my wife from our home to the hospital. I won't go into details as it's quite sensitive, but I would like to encourage the court to look at that."
Both Mr and Mrs Bosch have also provided the inquiry with full written affidavits outlining their experiences.
Mr Bosch added that his relatives in South Africa - including his doctor father - were surprised that a woman whose waters had broken would be sent home from hospital, but he said the couple were "not given any option to stay".
"I am strongly of the opinion it's unethical, especially for people who live remotely as we do," said Mr Bosch.
The couple have since become parents to a daughter born in 2022.
Opening proceedings, Sheriff Principal Aisha Anwar said the loss of a child was an "unimaginable and deeply tragic event in any parent's life", but the purpose of the inquiry is "not to apportion blame".
She added: "It is to establish the circumstances and to consider what steps, if any, might be taken to prevent other children dying in similar circumstances."
The inquiry continues.
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