There was a "gross failure in basic care" which led to a baby being starved of oxygen during birth, a coroner said.
Zak Ezra Carter died at the Royal Gwent Hospital, Newport, two days after being born in July 2018 at Ystrad Fawr Hospital in Caerphilly county.
Gwent coroner Caroline Saunders said the monitoring of Zak and his mother Adele Thomas fell "well below the standards expected". She said she was reassured the health board had taken steps to improve care.
Ms Thomas told the Newport hearing she felt "scared" and staff "didn't care" when she arrived to give birth on 20 July 2018. In a statement to the inquest she described being turned away from the centre after going into labour on three occasions, before being admitted on the fourth.
Ms Thomas said she was initially offered paracetamol as pain relief at the midwife-led centre.
She described "a lot of arguing between nurses", one of whom was "bolshie and rude and rough handled me", adding the midwives "did not appear to be in any rush".
When Zak was born, he was described as being "white and pale" and without a heartbeat. He did not cry and was taken away to a room for resuscitation. Zak was transferred to the Royal Gwent Hospital where he died two days later.
During the first stage of labour, Prof Sanders said "everything was progressing at a normal healthy rate and the fetal heart rate was recorded as completely normal". But she said it was "highly unusual" for the heart rate to not be documented contemporaneously, and the midwives had not been able to explain why they had not done so.
Recording a narrative conclusion, Ms Saunders said the monitoring of Ms Thomas and her baby had "fallen well below the standards expected", leading to a "gross failure in basic care" of them in the later stages of labour.
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Source: BBC News, 18 March 2021