A grieving mum says she hopes lessons will be learned after a coroner blamed hospital failures for the death of her water birth baby.
Zachary Johnson died hours after being born at Walsall's midwifery-led unit in West Midlands, on October 16, 2016.
An inquest heard the tiny tot did not have his heart monitored because there was no waterproof equipment available and there were six failings that took place during and after his birth.
Black Country area coroner Joanne Lees ruled that gross failure contributed to his death.
Joanne Johnson, from Walsall, said: "We now have some answers but sadly it doesn't lessen our grief.”
Ms Johnson, speaking on behalf of the family including Zachary's father Steven, said the inquest's findings did not lessen their grief.
The 34-year-old said: "For the last nearly three and a half years, we have had no form of "closure".
"We have had so many unanswered questions as to why our little boy died.
"We first found there were problems with the care we received the day after Zachary died but had no idea of the severity of what had gone on during the night he was born.
"Myself, Steven, our daughters and our families still have to live every day without Zachary here with us, knowing he should be.
"We are grateful for the attendance of all the witnesses over the last few days and would like to thank our barrister, Julie-Anne Luck, for her tremendous support to us.
"We will be forever thankful for the few hours we were able to share with Zachary, which would not have been possible had it not been for the efforts of the team to resuscitate him on the delivery suite at the Manor hospital.
"The coroner has concluded Zachary's death was caused by the neglect of Walsall Healthcare Trust and in particular this was due to gross failures during Zachary's delivery and during his resuscitation.
"It is clear the coroner thoroughly investigated Zachary's death and we hope that the actions that she has demanded will prevent other families suffering the same heartache that we have."
The six failings included Zachary’s heart rate having not been monitored every five minutes during stage two of Mrs Johnson’s labour, as per guidance.
Further failures included failing to ensure a waterproof sonic aid was available to monitor Zachary’s heart rate while Mrs Johnson was in a birthing pool.
Coroner Lees said Mrs Johnson should never have been allowed to have given birth in a pool in the first place once midwives at the midwifery-led unit realised the correct equipment was not available.
But once in the pool, Mrs Johnson should also have been removed to ensure Zachary’s heart rate could be measured, while the resuscitation procedure carried out on the baby once he had been born, was also found to be incorrect and inadequate.
Coroner Lees will be issuing a prevention of future deaths report to the trust in due course.
It covers the absence of a specific directive or policy in relation to the use of the birthing pool in the absence of the correct working equipment, as well as the absence of mandatory refresher training on newborn life support.
Walsall Healthcare Trust will be asked to provide the number, type and whereabouts of sonic aids, both on the MLU and the main delivery unit, along with six months of audit reports on the monitoring of foetal heart rates.
The trust has been approached for a comment.
The midwifery-led unit in Charles Street re-opened in December after closing midway through 2017 due to staffing concerns.