Freya Murphy was born at 9.31am on 21 July 2018 at Queen Elizabeth University Hospital, Glasgow, and died there a week later, aged seven days and 12 hours. The cause of death was given as global ischaemic brain injury associated with a chorioamnionitis. A fatal accident inquiry took place at Glasgow Sheriff Court in November.

Karen Murphy, 32, a first-time mother from Cambuslang, South Lanarkshire, and her husband, Martin, had called for several recommendations to be made, including the routine screening of pregnant women for Group B Streptococcus (GBS). However, Sheriff Barry Divers concluded there were “no defects in any system of working which contributed to Freya’s death” and that the death “could not realistically have been avoided”.

NHS Greater Glasgow and Clyde said in a statement that the care was “below the standards expected” and confirmed that a key recommendation had already been adopted.

Sheriff Divers recommended that the health board review staffing levels across all shifts to ensure that its labour wards, postnatal wards, maternity assessment units and other hospital maternity-related areas are adequately staffed at weekends and in the evenings. This includes ensuring provision for a second operating theatre to be opened when two patients require admission to theatre simultaneously.

He also recommended that the health board formally request that the United Kingdom National Screening Committee (UK NSC) give urgent consideration to a review of whether pregnant women routinely be offered screening for GBS.

The determination stated: “It was clear on the evidence that all those clinicians (doctors and midwives) who spoke to their involvement with Freya, were motivated in their actions by doing what they thought was best for Freya and Mrs Murphy.

“For the reasons I have explained, I have not been able to make all the findings that they sought. However, I hope that the entirety of this FAI process, including the preparation for the evidence which was led, the submissions made and this determination, has at least addressed the questions which they have about what happened.”

Dr Claire Harrow, deputy medical director for acute services at NHS Greater Glasgow and Clyde, said: “We have received the findings from the FAI. The recommendation for NHSGGC on staffing has already been implemented.

“In line with the recommendation on Group B Streptococcus, we plan to make a formal approach to United Kingdom National Screening Committee.”