Katie Bowker was cared for by her midwife and friend Jenny Brown, pictured outside Manchester Coroner's Court on Monday
A midwife lost her own baby boy in childbirth after her friends and colleagues delivered him in hospital following a series of blunders.
Dexter Bowker was born on November 29, 2016 at North Manchester General Hospital but never took a breath. Medics felt a pulse in his umbilical cord after his birth, but could not resuscitate him.
At the time, his mother Katie Bowker, 39, was a midwife at Royal Oldham Hospital, which is also part of Pennine Acute NHS Hospitals Trust, and two colleagues had taken charge of Dexter's delivery.
But an inquest at Manchester Coroner's Court found medics had failed to pick up a slowing in Dexter's foetal growth towards the end of the pregnancy.
A community midwife who saw her at 26 weeks and at 38 weeks admitted she should have been sent for further scans.
It also emerged that the midwife who helped her in labour was due to have refresher courses on aspects of midwife care including neo-natal resuscitation.
Mrs Bowker, from Bury, who has a son called Harvey with her husband Adam, told the inquest of the horrifying moment she learned Dexter had died after first being placed on her chest.
Fighting back tears, Mrs Bowker said: 'I held his [umbilical] cord and could feel his cord pulsations,' she said. 'But I remember thinking, 'I haven't heard him cry.'
'I didn't realise how bad it was until Nic [Nicola Jagat Singh] took him off me. Jenny [Brown] pulled the emergency bell and then everyone came in.'
Mrs Bowker, of Bury, Greater Manchester, with her husband Adam Bowker, 34, and son Harvey
She added: 'I was thinking 'he'll come round in a minute, he will cry in a minute'.
'I remember them all looking at each other and shaking their heads because they couldn't do any more at that point.
Ms Brown (pictured in 2016), the midwife who helped her in labour, was due to have refresher courses on aspects of midwife care
'The consultant told us there was nothing else they could do. That was it really.'
Mrs Bowker was a supervisor to her friend and colleague Jenny Brown, her midwife for much of her labour.
Mrs Brown had delivered Mrs Bowker's first child Harvey but at the time was based on the hospital's post-natal ward and had not worked on the labour ward for 18 months.
The inquest heard her training compliance was at 44 per cent and she had requested 'refresher' courses so her skills, including neonatal resuscitation, were up to date.
When asked if she felt confident looking after Mrs Bowker, Mrs Brown said: 'I wouldn't have done it otherwise.'
But she had not obtained permission from the hospital's head of midwifery to be Mrs Bowker's midwife, although colleagues 'assumed' she had.
Mrs Brown initially provided care to Mrs Bowker in the hospital's birthing pool but when she came to the end of her 12 hour shift she handed over to night midwife Ms Singh, staying on only to take notes.
The baby was born in 2016 at North Manchester General Hospital but never took a breath
Both midwives were concerned by a rise in Mrs Bowker's temperature and had wanted to transfer her to the labour ward sooner but she'd refused, Ms Jagat Singh said.
Speaking after the inquest, Katie Bowker and her husband Adam, 34, released the following statement:
'Dexter was a very loved and beautiful little boy. We were all really looking forward to bringing him home and welcoming him to our family, none more so than his big brother, Harvey.
'He was only five-years-old when we lost Dexter and for him to deal with all this at such a young age is absolutely heartbreaking.