Theo Ilich photographed at Auckland City Hospital. His parents Joanne Rimmer and Karl Ilich want a full investigation into his death on May 10 2020.
She was woken in the middle of the night because her baby had died.
Theo Ilich, barely 48 hours old, was in an incubator so light therapy could bathe his jaundice.
His mother, Joanne Rimmer, lay beside him. It was the evening of May 9 and Covid restrictions meant her husband, Karl Ilich, had been sent home from the single room in Auckland City Hospital.
Joanne had been awake for three days and when sleep came it was in the expectation of being woken for the next feed around midnight, as planned, and to express breast milk.
That never happened. Instead, the nurse tube-fed Theo at about 11.20pm and then took a break.
Some time after that he vomited, and when the nurse returned after 1am she rushed his lifeless body to resuscitation.
Nine weeks later Joanne and Karl returned to the hospital to meet clinicians investigating their boy's death.
Joanne told the meeting the little sleep she's managed comes with visions of her son, lying alone in the early hours of Mother's Day.
"The hospital that night and the next day - the place was shell-shocked about what happened. There was a lot of very, very upset staff," a neonatal paediatrician told the parents.
"We are struggling to understand what happened and how this happened. We don't want anything like this to ever happen again."
Parents make police complaint
Theo's death comes amid a separate investigation at the country's biggest hospital, launched after a cluster of other unexpected deaths.
Four women died during or soon after pregnancy this year, a Weekend Herald investigation has revealed, with three happening after level 3 restrictions began on March 23.
One maternal death was recorded in the previous three years. Hospital bosses have ordered an overarching review, saying all women had one-on-one care and the causes don't appear related, but it's crucial to identify if there are any systemic problems.
Theo's death is being investigated by the coroner. Doctors initially assumed he could have suffocated after regurgitating his feed, because of the vomit and milk being found in his windpipe. However, there was no liquid in his lungs and the cause of death is as yet undetermined.
The DHB is carrying out its own investigation with input from a neonatal paediatrician from another hospital. Theo's case won't be included in the wider review into maternal deaths because it involves different services, it says.
Joanne and Karl have laid complaints with the police and Health and Disability Commissioner, which detail a litany of claimed problems in her care, including a dangerous medication error, a lack of observations, and confusion among staff over Covid rules.
They accept Theo's death may not be related to the hospital care. However, Joanne's own treatment means they question what happened.
"If I have to express my concern and ask for food or medication, how can I be certain that Theo got the right treatment," Joanne wrote in a signed statement to police.
"What was actually done by the hospital knowing Theo was a high-risk pregnancy?...my baby should have been the safest in the hospital."
'We had a healthy kid'
Joanne and Karl married in their early 20s and had a daughter, Brielle, a few years later. She was premature and not expected to live, but the 14-year-old now towers over both of them and excels in academics and sports.
When Joanne was pregnant with their next child she spent three months in Auckland City Hospital with severe complications. Chloe was born prematurely on March 27, 2017, and died the next day; her lungs collapsing under resuscitation.
Given that high-risk history, when Joanne fell pregnant with Theo late last year she was referred to the "gold standard" teams at Auckland DHB, despite living closer to Waitakere Hospital.
Her waters broke in the early morning of May 7 and at 35-and-a-half weeks pregnant.
Nine days earlier New Zealand moved from alert level 4 to 3, and hospitals were still on high alert and had strict policies in place to reduce any risk of transmission; it took some time to get seen on arrival, and Joanne found during her stay some staff would avoid touch.
Doctors wanted to delay the birth, advising she could be in hospital for a couple of weeks.
Joanne already had a community ultrasound booked for that afternoon, and let staff know. But the time came and went, she says, and only by her agitating were the sonographers contacted.
She walked the three minutes to the clinic, in pain and leaking fluid.
An ultrasound revealed abnormal blood flow through the placenta, and Theo was delivered by C-section that night - greeting the world with a "massive wail" that was music to his parents' ears after Chloe's silence.
Karl cut the umbilical cord, but while Joanne was being stitched up he was told to leave, the couple says, despite pre-approval to stay overnight.
Joanne - who has a fear of hospital that worsened after Chloe's death - became distressed, and eventually, Karl was allowed to stay for one night.
Still, that and the other issues hardly mattered.
"We had a healthy kid. We'd never had the experience of having the child in the room with us, they'd always been rushed off to intensive care," Karl says.
"He was a big boy [2.53kg]; the biggest child we ever had."
Restraint allegation
The next day Joanne says she was given her first meal since arriving at hospital some 33 hours earlier. There was meant to be one-to-one care, but midwives changed before they could learn their names.
About 5pm Joanne and Theo moved from the birthing unit to ward 98, a unit providing care to higher risk mothers and babies.
Joanne says no dinner came, and she had to ask for her medication, taken for chronic pain including carpal tunnel (on one earlier occasion she got too much, she and Karl allege, but luckily spotted the error).
The following day Joanne became wet with urine, which dripped on the floor, but says staff largely dismissed her embarrassed complaints. Eight hours later it was found the catheter wasn't properly in her bladder, she says, and by then the bandages over her surgical wound were wet.
Theo was vomiting after every other feed. Since birth, he'd been woken for supplementary feeds through a nasal tube (most babies born at 35 weeks are tube-fed, which is considered the safest method), but this seemed to cause some distress and breathing difficulty.
After a tube became dislodged he was finger-fed instead - sucking a little finger as a mixture of formula and breastmilk went in, to mimic breastfeeding. His parents say they asked for him to be fed this way or by bottle, rather than by tube.
Karl was unable to stay the night, but on the way out at about 8pm saw other fathers apparently permitted to sleep over. There seemed to be little consistency around the Covid restrictions, he says.
"Every nurse or midwife had a different idea of what you could or couldn't do. There was so much confusion."
After another finger-feed a nurse took Theo away and returned him with a feeding tube in his mouth, Joanne says; a more unusual placement and because of the breathing issues he'd had when the tube was in his nose.
She then used bandage material to tie Theo's arms to the side of the incubator, Joanne alleges, dismissing her objections and explaining it would stop him from hitting the feeding tube.
"When Theo came back he was tied to the incubator with bandages to his arms spread open," Joanne wrote in her signed police statement.
Auckland DHB responds
At the mid-July hospital meeting clinicians told Karl and Joanne they weren't aware of that allegation - there was no mention of Theo being restrained in medical notes or debriefing meetings.
A midwife with 30 years' experience told Karl and Joanne she'd never heard of, nor would consider, tying a baby in such a way.
And in a statement to the Weekend Herald, Auckland DHB director of midwifery Deborah Pittam said tying a baby's arms for the purposes of restraint "is not within our nursing and midwifery practice guidelines".
"We are fully investigating the care that was given to Theo with a panel that includes an external reviewer. We have met with the family and have offered them independent support, and will be meeting with them again to share the report from the review and answer their questions," Pittam said.
"While the full review isn't complete and we don't want to predetermine any findings, our initial internal review has shown that staffing numbers were adequate on the ward the night that Theo passed away.
"We have received complaints about the care of Theo's mother, Joanne, and were sorry to hear of her experience. We are looking into these via our complaints process."
The DHB wouldn't make more detailed comment. At the hospital meeting, Karl and Joanne were told the nurse stayed with Theo after the last feed to check his heart rate, oxygen saturation and breathing. Burping wasn't needed, they were assured, because air isn't swallowed during tube feeding.
Karl and Joanne asked why she wasn't woken together with Theo for his last feed, as had been instructed by staff and in order to express breast milk.
'You just play through it all in your head'
The couple are plagued by nightmares about not being able to help their baby.
"We were robbed. Jo should have been woken for that last feed - she was due to express, she could have noticed what was going on. If the hospital hadn't kicked me out I would have been awake for that last feed," Karl says. "You just play through it all in your head."
Covid-related restrictions heightened the pain and "what if" questions for other families who lost loved ones during lockdown.
The husband of one woman wasn't allowed at hospital when they lost their baby at 21 weeks' gestation and was called hours after her emergency C-section and told she was in intensive care with a blood infection.
He was finally allowed to join her, sitting beside her bed and in personal protective equipment. The next morning she died.
"My young family's shock and grief over the two sudden deaths was made much worse by woeful communications from hospital staff, and the heartless restrictions of the alert level 4 lockdown," the man, who asked not to be named, told the Weekend Herald.
A worker at Auckland City Hospital told the Weekend Herald pressure related to staffing and workload was worsening, with high staff turnover, and such a number of maternal deaths "just shouldn't be happening this century".
It was unusual for a baby to have an orogastric (mouth) feeding tube as Theo did and be on a postnatal ward and not in neonatal intensive care, they said. The nurse on duty was very experienced and well regarded, they said.
"ADHB's maternity system is in dire need of more staff - the nurse responsible [during the shift Theo died] likely had a high load of patients. The maternity departments are drastically flawed."
Auckland DHB strongly rejects that, saying it's unaware of any adverse events linked to staffing levels, including Theo's case.
Tube feeding is not uncommon on the postnatal ward, Pittam said.
"We have nurses and midwives in both settings who are experienced in safely and appropriately administering feeds via orogastric and nasogastric feeding tubes. The decision about which feeding tube is used is tailored to the baby's needs."
READ MORE:
• Auckland City Hospital investigates four deaths of mothers - husband speaks of being kept from hospital under lockdown
• Maternity shakeup: Auckland DHB considers stopping women outside its boundaries from booking services
• PM Jacinda Ardern on strained Middlemore maternity services: 'consistent underfunding'
The DHB declined a Weekend Herald Official Information Act request for correspondence regarding safe staffing and care in maternity services, and for related documents from this year. That would "require significant manpower beyond that which is available", the DHB replied.
Previous OIA responses show Auckland DHB last year expressed concern to the Ministry of Health about the growing demand put on its maternity services, and all DHBs are grappling with a global shortage of midwives.
"There has been a significant improvement in general morale amongst our still pressured staff," hospital advisory committee minutes from March noted on the midwifery workforce.
"We remain in a position where any increase in sick leave amongst staff and any resignation is felt within the service".
David Wills, director of the Nurses Society of New Zealand (NSNZ) union, said there had been past midwife workforce shortages at Auckland DHB and other health boards. However, the workload for hospital staff generally dropped significantly during the lockdown as some services and procedures were postponed and more patients stayed away.
It was normal for babies born around 35 weeks to be cared for in a postnatal ward, Wills said.
"If a baby needed to be in NICU (neonatal intensive care unit), it would have been in NICU. And, generally speaking, if any preterm baby had breathing problems they would be in NICU."
Both the NZ Nurses Organisation and the College of Midwives declined to comment.
Detective Inspector Uraia Vakaruru of Auckland City Police confirmed a complaint had been received, and police were investigating on behalf of the coroner.
"As we are in the early stages of our investigation we are unable to comment further."
'Within hours' of another tragedy
Joanne claims her observations including blood pressure weren't done on the night Theo died (contradicting medical notes released to her), and that when she left hospital a urine sample provided the previous day hadn't been collected.
On the day of her discharge on May 10, she went to her GP, who realised her wound was infected and prescribed antibiotics.
A few days later a midwife visited and found her blood pressure was high, telling her to check again with the GP that night. He sent her straight to hospital, and three medications were tried before one finally worked.
"I've just lost my son and they [hospital staff] are telling me my wife's blood pressure is fatally high," Karl says. "We came within hours of losing my wife."
The peculiarities of having Auckland split into three DHBs rubbed salt in their wound; support like counselling required special sign-off (and dried up) because they live outside of Auckland DHB's boundary, they say, despite being referred there.
A social worker arranged a food package, but it couldn't be delivered to West Auckland. She drove it out in her own time.
(The day the Weekend Herald lodged questions with the DHB, Karl and Joanne were told they'd get free counselling.)
The couple are private people. However, they decided to speak up for Theo.
When Joanne's waters broke it was still dark, and she and Karl watched the sunrise over the Hauraki Gulf while waiting in the women's assessment unit.
They lost Chloe in the same hospital, but this felt like a new dawn. Karl started singing a family favourite, the Circle of Life.
"The sun was on Jo's belly, and it just felt really warm, natural and spontaneous," he recalls.
"It just felt special. Like this was different."
Kamahl Santamaria's case moved to the Employment Court for faster resolution.