Serious failings of a maternity ward doctor and midwife may have contributed to the death of a twin baby girl, a coroner’s court has heard.

Two-day-old Lucy Wood died at St George’s Hospital after spending her short time on life support after suffocating during her delivery at Kingston Hospital in June 2009.

Obstetrician Naguib Naguib admitted failing to take charge of the high risk birth, leaving midwife Tatyana McGill alone in the delivery room when she lost track of Lucy’s heartbeat on a monitor.

He said had he known of complications he would have started the birth earlier, a move that expert witness Dr Nicholas Morris said could have saved Lucy’s life.

Mr Naguib said: “Had I broken her waters I could have made an emergency delivery in, I estimate, between five and 15 minutes.

“I admit I should have been more robust, but I trusted the midwife on duty.”

Mr Morris, senior obstetrician at Portland Hospital, London, concluded the 40 minute gap between losing Lucy’s heartbeat and her birth was the primary reason for her death.

He said: “This was a pre-term high-risk pregnancy and it is difficult to understand why the staff involved didn’t prioritise this birth. The doctor should take charge but in this case that did not happen.

“If Lucy had been delivered when she should have been then I suggest we would not be here today, though it is difficult to say what condition she would have been in.”

A damning report carried out by Local Supervising Authority Midwifery Officers criticised midwife Mrs McGill for failing to properly examine the foetal monitor and failing to communicate with the obstetrician.

Midwifery expert Shania François said Mrs McGill failed to follow basic midwifery practice by not calling for help when she lost Lucy’s heartbeat.

She said: “If you are having trouble, then you call the doctor, you call the senior nurse or you call for another midwife.”

Both Mr Naguib and Sister Ni, the senior nurse on duty that night, had not seen a serious incident report into the death until two weeks before the inquest, the court heard.

Coroner Dr Peter Ellis said: “Why the individuals involved are not given a report into an incident where a baby has died in their care as a matter of course is baffling to me.”

Mr Nicholas Anim Nyame, consultant obstetrician and risk management lead at Kingston Hospital, admitted Lucy’s care was “sub-standard” and said copies of the serious incident report probably should have been given to Mr Naguib and Sister Ni.

He also said the hospital had brought in new measures to cope with high risk twin pregnancies including having senior doctors on the labour ward 98 hours a week.