First-time mum Jessica Beazley had just four days to nurse her baby boy Nathan before making the harrowing decision to turn off his life support.
Aged 20 at the time, Ms Beazley had not known what to expect during her pregnancy, but she had instinctively felt something wasn't right.
Now, almost a decade later, she and husband Ryan Beazley have confirmation something was very wrong and the care they received at Mackay Base Hospital where Nathan was born had "caused harm to both" Ms Beazley and their baby.
"I told them that my baby was not growing, and something felt wrong," Ms Beazley said.
"I came out of most appointments feeling like a stupid young first-time mum and any concerns [were] brushed off.
"I told them time and time again that I couldn't feel much movement."
Nathan was born by emergency caesarean at the regional Queensland hospital in November 2013 but had to be flown to Townsville for specialised care where he died just days later.
'Absolute hell'
The Mackay Base Hospital's obstetrics and gynaecology department has been under investigation since October last year, following complaints from women who had suffered complications from caesareans and suggestions of patient harm.
A report into the hospital was delivered to the Mackay Hospital and Health Service (HHS) chief executive earlier this month.
Queensland Health Minister Yvette D'Ath is expected to respond to the report at a public meeting in Mackay on Friday.
Following the announcement of the review, a consumer case management pathway was put in place to give women the chance to have their care at the hospital reviewed by a member of an independent clinical review committee.
Ms Beazley called the hotline and underwent the process of having a full review of her medical records and the opportunity to discuss her experience with a member of the panel.
She said the past nine years had "been absolute hell".
"I am a shell of myself still. I had no choice but to come forward and seek answers for myself," Ms Beazley said.
Last month, Ms Beazley received the findings.
The letter from the review committee stated:
"We have determined that your care caused harm to both you and Nathan.
"Your care fell below minimally accepted standards in the following respect.
"As your baby was small (on the fourth percentile, which is much less than usual), you should have had ultrasound scans at 28 and 34 weeks.
"This did not occur, even when there was evidence of that your fundal height (top of your uterus measurement) did not increase.
"This was recorded in three consecutive antenatal visits, and you had raised concerns yourself about the growth of your baby."
The letter also stated:
"Our review has made it clear that there were also many deficiencies in the communication with you and Ryan, both before and after Nathan was born.
"We also noted that the documentation of your pregnancy by the Mackay Hospital and Health Service was inadequate."
Concerns brushed off
Ms Beazley said when they returned to Mackay, she was never told why Nathan had died.
"I thought something was wrong with me," she said.
"At each visit I [had] questioned why my baby wasn't growing. I felt funny, I felt like oxygen wasn't going around my body."
After the funeral, Ms Beazley received a phone call from a midwife to check up on baby Nathan.
"My husband had to explain 'He's not here'," she said.
"The poor quality of communication between staff, as well as between staff and patients, is unacceptable."
The Beazleys met with the Mackay Hospital and Health Service's patient safety and governance team in 2014 seeking answers about what had happened to their son.
A transcript of that interview, seen by the ABC, recounts the extreme emotional stress and physical toll that Nathan's death had on the couple and their frustration that concerns they raised during the pregnancy about a lack of growth were "brushed off".
"Staff made comments about, '[You] should be happy you're going to have a small baby as it will make for [an] easier delivery,'" Ms Beazley told the meeting.
A system failure
Ms Beazley and Mr Beazley have since had two healthy children; one-year-old Isabella and Lincoln, aged two.
They paid to deliver both babies at a private hospital.
"Going through the private system, I was shocked and extremely emotional at the difference in care," Ms Beazley said.
"When I started to hear about all these horror stories [at Mackay Base Hospital], it was like living through it all over again.
"I fear for the women of Mackay. Not everyone can afford private health."
Ms Beazley has called for an overhaul of the system.
"It's not just a one-staff member issue. It's an entire culture within the industry," she said.
"There's so much that needs to be done to regain the trust of the women in this region.
"I urge any mother in light of what's come out recently; please do not ever stop pushing until you feel heard."
Former chief executive of the Mackay Hospital and Health Service Lisa Davies Jones apologised in a letter to Ms Beazley that her "care experience was not in line with [the hospital's] organisational values".
"Sharing your story is incredibly valuable," Ms Davies Jones said.
"Please know that the learnings from hearing those experiences, together with the outcomes of the independent investigation, sets a strong foundation for the obstetrics and gynaecology services moving forward.
"We look forward to welcoming you to Mackay HHS in the future."
