The death of a two-day-old baby in Street has prompted Taunton and Somerset NHS Trust to review the care it offers new mothers.

But despite the changes made by the trust, an inquest last week heard that four of the midwives who visited baby Ruth Kolind in the two days before her death in 2007 still have not had training on how to fill in neo-natal records.

Coroner Tony Williams also raised concerns about the co-operation between doctors and midwives in newborn care.

Ruth Kolind was born in Street on December 28, 2007, and was ten days earlier than expected. She was so keen to make her appearance in the world that her planned hospital birth was abandoned for a home birth.

But on December 30, two days old and less than two hours after a visit from a midwife, Ruth was found in her cot unconscious and not breathing.

Frantic resuscitation efforts by her father, paramedics and an air ambulance crew could not save her and she was pronounced dead at Bath Royal United Hospital at 3.15pm.

An inquest held at Wells Town Hall last week was told how Susan and Rasmus Kolind repeatedly raised concerns about their daughter to four midwives and a doctor, who said she was well.

The three-day inquest into the circumstances surrounding Ruth's death was, Mrs Kolind pointed out, longer than her daughter had lived.

The court heard how on-call doctor Robert Anderson had visited Ruth when she was five hours old and had failed to leave behind a report for midwives to read.

Instead, he typed notes on to the computer at Vine Surgery, to which the midwives did not have access.

Midwives giving evidence at the inquest, including Mary Gillies, Mary Richards, Helen Crandon and Arlene Batstone, told the coroner how they had no concerns about Ruth's health when they visited her at her parents.

But they all agreed Mrs Kolind had voiced her concerns about feeding her baby – who weighed just 2.5kg.

However, a lack of training in paperwork had led to confusing and potentially misleading medical records, as midwives filled them in according to their own interpretations of what was required.

Speaking at the inquest, Sallyann Tennant, head of midwifery for Taunton and Somerset NHS Trust, said an investigation into the circumstances around Ruth's birth had prompted changes in care for newborns, including reluctant feeder guidelines that mean that if a newborn baby has not fed for 24 hours, they would be referred to a paediatrician.

Tragically, under the new guidelines, Ruth would have been referred to a paediatrician on December 29, a day before she died.

"She would have been seen quickly and no one can say what may have been discovered," said Mr King, the Kolind family's barrister.

"The reason that the NHS implemented this policy is because it is simply the right thing to do if a newborn baby hasn't eaten for 24 hours.

"Surely, if the care that Ruth would have received now is appropriate now, it would have been appropriate then."

Mrs Tennant said that 2007 had been "a long time ago" in medical terms.

"We are always learning new things, and implementing new policies and strategies," she said. "We learn new things all the time in medicine."

Closing the inquest, coroner Tony Williams ruled the cause of death for Ruth Kolind was natural causes, after becoming infected with a group B Streptococcus infection.

However, he will be writing to the authorities, outlining his concerns about doctors not giving midwives proper access to newborn baby reports and other information that should be made available to them.

He also voiced concerns about "a total lack of form-filling in, inadequate form filing, failure to read previously left notes and a lack of understanding of records" by some of the midwives, and will write to the Taunton and Somerset NHS Trust outlining his concerns about training.

He also thanked the Kolind family for their patience during the inquest.

"I am very grateful to you both," he told Mr and Mrs Kolind, as he closed the inquest.

"I am sorry for the loss of your daughter, but I hope that in this inquest you have had some explanations."