A Merseyside council was slammed today over a catalogue of failings which led to a huge tree falling onto a heavily pregnant mum's car - killing her baby.
Liz Stear was 36 weeks pregnant and driving along Arrowe Park Road in Wirral , when a large horse chestnut branch toppled onto her Audi A4, smashing through the windscreen and thudding into her abdomen.
The baby, named Lucia, was born via emergency C-section, but died in hospital at just 15 hours old following the incident on November 10, 2016.
Today, a two week inquest finished, with a jury deciding upon a hard-hitting verdict which revealed how Wirral Council were repeatedly at fault before the tragedy.
And because a similar "near miss" tree fall in early 2015 wasn't probed correctly, there was nothing to prevent Lucia's sudden death, Liverpool Coroner's Court was told.
The tot died as a result of an "accident", which was contributed by the local authority "not having a proactive, robust tree management system in place for Parks and Countryside up to November 2016".
The verdict added: "There was a complete failure to have a policy in place for tree management in Parks and Countryside, and a complete lack of risk management for trees at risk of falling onto highways.
"There had been no formal inspection of trees in Arrowe Park for 13 years previously."
In January 2015, almost two years before, no lessons were learnt from a different tree falling into Arrowe Park Road.
The narrative verdict continued: "Inadequate steps were taken to investigate the failed beech tree that fell into Arrowe Park Road in January 2015, and rectify mistakes that had been made, including failing to recruit and employ specialist staff for tree management.
"Had this incident been appropriately investigated, remedial work to the trees along the boundary of Arrowe Park Road would have been carried out.
"There were missed opportunities to prevent further serious incidents, despite staff concerns and a near-miss event taking place."
A jury also agreed that the horse chestnut tree which fell on Mrs Stear's car was clearly riddled with "bleeding canker" which would have been evident for the past four years.
The verdict said: "There was inadequate training of Parks and Countryside staff with regard to tree management and identifying tree hazards, there was no programme of mandatory, ongoing training and there was no arboricultural officer employed by Wirrral Borough Council since 2003."
Finally, the jury found, "there was a systemic lack of accountability and poor communication within and between departments in Wirral Borough Council".
The mum-of-three said she felt a "niggly period-type pain" when she was in the ambulance, and repeatedly asked to be taken to nearby Arrowe Park Hospital the hospital, just yards from where the accident happened.
But Mrs Stear, whose two other children were in the car at the time, was instead taken to Aintree Hospital.
The court, sitting in Kirkdale, heard: "...a midwife could not locate Lucia's heart rate.
"At 9:10am a fast-scan was performed, which showed that Lucia's heart was beating slowly at approximately 60 beats per minute.
"Lucia was resuscitated by teams from Aintree Hospital and Liverpool Women's Hospital and then North West Ambulance transferred Lucia to Liverpool Women's Hospital arriving at 12:40pm.
"Tests showed that Lucia had multi organ failure and was extubated and died at 01:11 on 11th November 2016."
A baby is considered to be full term if he or she is born anytime from 37 weeks to 42 weeks, meaning Ms Stear's pregnancy was just before that stage.
At Liverpool Coroner's Court, in Kirkdale, legal representatives from Liverpool Women's Hospital, Wirral council. North West Ambulance Service, Merseyside Police, the Health and Safety Executive (HSE) and solicitors acting for the Stear family, all attended the proceedings.
So far, the Stear family have not wished to comment.