All three died within hours of their births. Leo died at Monklands Hospital on 15 February 2019. Ellie and Mira-Belle both died at Wishaw General: Ellie on 5 March 2019 and Mira-Belle on 2 July 2021.

In her determination, Sheriff Principal Aisha Anwar KC made 11 recommendations including in relation to the creation of a ‘trigger list’ to identify and assess early labour symptoms, guidance on when women should attend for clinical assessment, a review of electronic records and the introduction of a direct telephone line to maternity units for ambulance crews.

Sheriff Principal Anwar also observed that the health board should preserve and retain a copy of a mother’s electronic records.as soon as possible after a neonatal death is reported to the Scottish Fatalities Investigation Unit of the Crown Office.

Procurator fiscal Andy Shanks, who leads on fatalities investigations for the Crown Office said: “The tragic deaths of Leo, Ellie and Mira-Belle have been an overwhelming loss for their families and they have my deepest sympathy for all they have suffered.

“I hope that these proceedings provided the families with the answers they sought, and the sheriff principal’s determination, which is extensive and detailed, helps to prevent similar deaths in the future.”