There are two boxes on top of each other on Laura Mallin's bookcase.

The tiny box contains her son's ashes.

The larger one has his birth certificate, hospital tags, the beanie he never got to wear, photos and a silver bracelet engraved with his name "Zachary Anjo", which is angel in Portuguese.

Laura Mallin still has questions about why her son Zachary Rovani Neves died on May 28.

She also wants accountability from the Waitematā District Health Board and has lodged a complaint with the Health and Disability Commissioner.

"My baby died because the medical staff didn't do their jobs properly. It was a series of human errors; the duty of care was negligent, which resulted in the wrong outcome for me," Mallin told the Herald on Sunday.

"I am devastated and feel numb. It was a month ago. I have had an apology from the DHB but that's not going to do anything. It can't bring back my child, it's not enough.

"My world has taken this massive tumble, a part of me died when he died. There should be more accountability, we do make errors but these are big mistakes that caused my baby to die. It was negligence and a lack of care."

The couple have received a letter of apology from the DHB's Maternity Services unit.

An "adverse event" investigation into Zachary's death identified a lack of information sharing and the baby's size and weight being incorrectly recorded. There was also a shortage of beds at North Shore Hospital.

"With the benefit of hindsight had Laura been admitted overnight for repeat monitoring it may have been possible, although unknown to have saved Zachary," it concluded.

Baby Zachary was stillborn on May 28. Photo / Supplied

Maia's baby brother

Mallin, 34, was excited when she fell pregnant in October with her second child, a boy.

Her Brazilian partner Bruno Rovani Neves, 37, was looking forward to teaching his son how to play football and their daughter Maia, 2, couldn't wait to be a big sister.

"She would kiss my stomach and say 'baby boy'."

A devastated Mallin would later have to explain to her daughter that Zachary was now "with the angels".

Apart from the usual morning sickness, Mallin's pregnancy was straightforward. Around 32 weeks she asked her midwife for a 4D scan but the midwife didn't think that was necessary.

Five weeks later, Mallin had a routine check with her midwife and discovered her baby was small.

"She said the baby was measuring at 37 weeks but it hadn't grown. Every time she measured my stomach, he was growing so he should have been measuring 38 weeks.

"She recommended I have a scan. He was moving but he wasn't a regular jab-jab, kick-kick baby. I noticed his movements had decreased but I didn't know what 'normal' was."

Mallin said "panic set in" in mid-May when she was 37 weeks' pregnant and had to wait eight days for a scan.

The scan at Mercy Radiology in Takapuna took longer than usual. The sonographer confirmed the baby was low in liquid and was measuring smaller, but his heart was beating.

"I had thoughts in my head that something wasn't right but I was told everything was fine and to go home."

The next day Mallin rang her midwife, she had concerns her baby wasn't active. She was advised to go to North Shore Hospital for a scan but was told that the hospital was "chocka".

Mallin was redirected to Waitākere Hospital, which made her feel uneasy.

"I had a gut instinct and wanted to lie to say I couldn't get there; now I wish I had listened to my instincts."

The first 40 minutes of the 90-minute CTG (cardiotocography) procedure showed the baby's heart rate was normal - until the mother-to-be developed cramps and felt her stomach tightening.

"The baby started to move rapidly which was really unusual because I hadn't been feeling him. I could see his feet at the top of my stomach.

"The senior obstetrician said everything was good. As we were getting ready to leave, the baby's heart rate significantly dropped so we were monitored a bit longer.

"The registrar came in and looked concerned. He wanted us to go back to North Shore Hospital. He said, 'this is unusual and shouldn't be happening.' But the obstetrician said our baby was healthy and it was too early for him to be delivered.

"I had pains but was told 'you are not contracting' so I was sent home."

A devastated Laura Mallin had to explain to her daughter Maia, 2, that her baby brother was now "with the angels". Photo / Supplied

'I just wanted my baby to come out'

On the way home, Mallin felt a sharp pain and thought it was the baby moving. She didn't know this would be the last time she would feel her child.

The staff at Waitākere Hospital suggested Mallin go back to North Shore Hospital in two days' time for more monitoring. She called her midwife the next day because her baby wasn't moving much and asked to have a C-section.

"I didn't want to wait any more. I just wanted my baby to come out," she says.

"The staff at Waitākere told me they wouldn't have done an induction or a C-section on that day because there wasn't enough staff and we were doing fine."

But Mallin instinctively felt something was wrong during the CTG at North Shore Hospital.

"The on-call midwife was mucking around for ages unable to find a heartbeat. She put it down to the machine being old. I began to panic until there was a faint heartbeat but I didn't realise it was mine.

"My midwife tried without success so I knew it was something serious. The registrar came in with a portable machine and I will never forget his words: 'I am sorry there is no heartbeat.'"

Mallin was given the option of giving birth to her stillborn son naturally, instead, she opted for a C-section.

"A natural birth would have taken days, I didn't want that. He was my son but he was dead.

"It was heart-breaking but I just wanted him out. It wasn't fair on me or fair on him. When he was born, he looked perfect, we had time with him but I wish it had been a lifetime. "

Meanwhile, Mallin's best friend had just given birth to a healthy baby girl in the maternity wing.

"We met at antenatal classes and moaned about our pregnancies but we planned to do everything together with our babies. She feels she has lost me. When I went to see her I gave her a huge hug, held her baby, and she cried.

"I told her to be brave and went back to my dead baby who was cold. My stomach is empty, the baby I carried for nine months is not here. I have milk I can't use and I have nothing to hold in my arms. I feel useless. A year of my life has been wiped."

Laura Mallin and Bruno Rovani Neves want someone to accept accountability for their son's death. Photo / Mike Scott

DHB apologises after 'adverse event' investigation

The couple have received a letter of apology from Maternity Services at Waitematā District Health Board.

A draft report by associate clinical director Denys Court outlines a series of mishaps that occurred:

• Electronic information from Mallin's midwife had not been passed onto Waitākere Hospital staff.
  • The baby's size and weight was a lot smaller than what was recorded.
  • Contradictory statements about the liquor volume, describing it both as "normal" and as "low".

In summary, the report indicates a small gestational age (SGA) baby with reduced amniotic fluid. The draft report said a history of reduced foetal movements was a reasonably common occurrence and should be monitored by a CTG to assess both movements and foetal response.

"With Zachary, there were good movements recorded on the trace and also good accelerations were reassuring. However there was also a heart rate deceleration that was not normal, and should have raised concern," the draft report says.

"It is clear that Laura had other risk factors such as reduced liquor and a borderline small for a gestational baby; all this increased the risk but not necessarily to the point where immediate action was necessary.

"With the benefit of hindsight had Laura been admitted overnight for repeat monitoring it may have been possible, although unknown, to have saved Zachary," the draft report said.
It also acknowledged there were not enough beds at the birthing unit at North Shore Hospital.

While medical staff had taken Mallin's concerns seriously, Court's report said: "I accept that Laura did not feel heard, and that is very much regretted."

The reason why Mallin was discharged from Waitākere Hospital was because "the staff believed that the clinical picture (normal growth, normal liquor, and reactive CGT) was sufficiently reassuring to safely is discharged with a plan to re-admit for re-assessment in 2 days".

"In retrospect, the growth had been plotted incorrectly and the liquor volume was low (not normal as was reported)."

Waitematā DHB told the Herald on Sunday in a statement that staff were "deeply saddened for Laura and Bruno, for the devastating loss of their son Zachary".

"Senior staff have met with the family, as part of the investigation, to discuss their views and to express our sincere condolences and sadness, for this very painful loss.

"Consistent with open disclosure, we have shared the draft report with the family, as part of this process. However, the report is not yet finalised. Once the investigation is concluded and any changes to practices or improvements are identified, they will be included in the report and an implementation plan will be initiated immediately.

"As the review process is still underway, at this stage, we are unable to comment further."

Mallin's midwife would not comment while Zachary's death is being investigated and for privacy reasons.

There will be no inquest because coroners do not have the jurisdiction to investigate a dead foetus or a stillborn baby.

Baby Zachary was delivered stillborn by C-section after a doctor advised that no pulse could be detected.

'Don't be naive and believe the medical professionals are always right'

The benefit of hindsight is cold comfort for Mallin, who believes the mistakes could have been prevented.

"When people say 'we can learn from this,' there is nothing I can learn from my baby dying. If I was listened to and they had the correct information I would have my baby in my arms but instead, I had to walk out of that hospital and carry my son in a Moses basket to be cremated.

"I have been cheated out of my future. It is horrific. There needs to be accountability."

Mallin is grateful to Baby Loss NZ for their support and Heartfelt, a service which provides photographic memories of stillborn babies.

She is speaking publicly to encourage mothers to trust their maternal instincts and to ask questions.

"Maternal instinct is more important than anything else. I knew my body and I knew my baby. I blame myself for not trusting my instinct and not kicking up a fuss.

"If you feel there is something wrong go straight to the hospital and demand a test or scan. When people say 'we can learn from this', well there is nothing I can learn from my baby dying. I believe his death was preventable."

Mallin plans to keep the box of Zachary's ashes close to her .

"When I die, he will come with me, he's always going to be with me. He's not going anywhere."