The devastated parents of a two-year-old boy who died waiting two hours in an emergency room blame the health system for their son's death.
Shadrach Sumaru and Kathryn Ram said their son Isaiah had developed a mild fever on September 24, and had asked for an ambulance twice in the hours leading up to his death on September 26.
Despite him struggling to breathe, the couple claim they were told there was no need for him to be taken to emergency and to give their son paracetamol.
They called again the following day but were rejected.
"They told us 'we are not going to take your son to ED, there's no reason for him to go'," Ms Ram told 9 News.
But when Isaiah's health worsened overnight, the couple rushed him to their local GP, who immediately called an ambulance and was sent to the emergency ward.
But while they waited at Dandenong Hospital his condition worsened and despite this, Isaiah's parents said they were made to wait more than two hours for treatment.
Ms Ram said she noticed her son's feet started changing to a purple colour.
"My son was in Shad's lap and his last word was 'juice', so I gave him juice," Ms Ram said.
"He took that juice and all of a sudden his tongue swelled up, his eyes started rolling."
The heavily-pregnant mother said all she remembers is the doctor saying "code blue" and then 20 people in there and "just pressing my poor baby, his heart rate stopped."
Isaiah went into cardiac arrest and died that afternoon, 9 News reported.
Mr Sumaru told The Herald Sun: "There was so much miscommunication and mismanagement."
"I just don't want this to happen to anyone else."
According to 9 News, the family said they haven't heard from the hospital at all and were told Isaiah may have died from pneumonia.
The government has ordered an investigation but it could be months before Isaiah's parents get the answers they need.
"Obliviously our hearts are with the family who have lost their beautiful little boy," Health Minister Jill Hennessy said.