A young mum desperately pulled a feeding tube from her baby's nose after she says it was incorrectly pushed into his lungs instead of his stomach.
Makerita Sio Eletise told the Weekend Herald she had concerns about the feeding tube but a nurse insisted it had been inserted correctly. Moments later she watched in horror as blood came out of 5-month-old Stephen's nose.
She says there was "terror in his eyes" and he struggled to breathe as his lungs filled with milk from the tube.
Eletise's allegations are being looked into by staff at Starship Children's Hospital.
However, an Auckland DHB spokeswoman said it would not comment on the care of her son while a review was under way.
After seeing the blood, Eletise says she begged the hospital staff for an X-ray to check the tube had been inserted correctly. She says the X-ray showed the tube had not been and his lungs were filling with milk.
The 29-year-old said she immediately yanked the tube out. Still struggling for breath, Stephen was then rushed to the hospital's Paediatric Intensive Care Unit (PICU) where he stayed for seven nights.
He was given oxygen and another tube was inserted into the right underarm to suck out the liquid and leaking air from his lungs. Stephen spent a further two months in hospital recovering from the ordeal.
Eletise says Auckland District Health Board needs to take responsibility for what she believes is a mistake and changes need to be made to ensure no other family has to go through the same horror.
"My son could have died that day," she said.
An Auckland DHB spokeswoman told the Weekend Herald patient safety was the top priority for the Starship team.
"We take concerns expressed by patients and whānau very seriously and have a robust review process."
Eletise says the hospital never apologised to her or her husband and instead tried to talk her out of filing a complaint against the nurse.
"My husband and I had a meeting with the doctors and they said there was no point blaming anyone as they needed to focus on saving our son's life.
"We wanted our son's life saved too, so we dropped it."
Now she's decided it is time to share their story.
"I was worried about speaking out but then I thought what if this happens to my cousin's babies or someone else I love and I did nothing," Eletise said.
The family - who live in Samoa - came to New Zealand last September so Stephen could get surgery to treat a cystic hygroma in his right cheek and under the floor of his mouth, a condition he was born with.
A cystic hygroma is a fluid-filled sac resulting from a blockage in the lymphatic system affecting critical structures such as nerves, blood vessels, and the airway.
Stephen has relied on getting his nutrition through a feeding tube since he was born.
He had a tracheotomy, a surgical procedure to help open his airway, in October. On December 29, the day he was meant to be discharged from hospital, the tube incident occurred.
It wasn't until last Friday Stephen was finally discharged from hospital. The ordeal has meant the family is yet to return to their loved ones in Samoa.
Eletise said Stephen has now made a full recovery and will be heading back to Samoa in two weeks.