He was born in Western Australia's only public maternity hospital in August weighing 4.1 kilograms and was considered full-term.
Tommy Starkie's heartbroken parents are determined to find out why he lived for only 23 days.
He was born in Western Australia's only public maternity hospital in August weighing 4.1 kilograms and was considered full-term.
But less than a month later, Manjimup farmers Alana and Paul Starkie were mourning his death.
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"My son, our son, was born dead, not breathing, no heartbeat," Mrs Starkie told 9News.
"They resuscitated him after two minutes and he lived for 23 days but he had catastrophic brain damage."
They were left with just his ashes, a few precious memories and unimaginable grief.
"You never think that's going to happen, you don't think that'll happen, that's what happened," Mr Starkie said.
The final stage of Mrs Starkie's labour is yet to be explained.
Aged 37 and considered a high-risk pregnancy, she was induced at 38 weeks and six days.
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During her 5½ hours of labour she was seen by midwives, not an obstetrician, normal practice at King Edward Memorial Hospital.
It's the last hour she's desperate for answers about.
Mrs Starkie said her contractions stopped and it was only when Tommy became stuck - a condition known as shoulder dystocia - that a code blue was called and an obstetrician came, releasing him.
"I couldn't cope with the pain and I told them that and I said, 'Something's wrong, something's wrong, something's not right, I'm in so much pain, we need to get this baby out, we need to cut the baby out', that's what I told them," Mrs Starkie said.
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The couple has since met with doctors at King Edward but have had to request Mrs Starkie's medical records from the birth via freedom of information laws.
They were told that could take three months. The process was sped up once police became involved but the Starkies were still yet to receive their son's medical record.
"They have that data, we couldn't get it, we're begging for this," Mr Starkie said.
"You can imagine, our son's not moving, we're trying to ascertain what's wrong.
"You ask the question, 'Can we have that answer', in an 'open disclosure' meeting in black and white.
"We couldn't get it. We couldn't get it."
It's hard to imagine but Mrs Starkie's experience gets worse.
When she was still in pain after being discharged five days after giving birth, her GP in Bridgetown sent her for an MRI, which revealed she'd been sent home with a tear in her uterus.
She said staff at King Edward didn't mention the uterine tear despite a hospital ultrasound on September 1 finding the "possibility of a uterine or broad ligament structure tear" and "significant volume of hemoperitoneum" or internal bleeding.
"I didn't find that out because the hospital didn't tell me," Mrs Starkie said.
North Metropolitan Health Service chief executive Robert Toms said it was undertaking a "thorough investigation into the care provided".
"We apologise sincerely to Mrs Starkie for her and her family's distress and are deeply saddened by their loss," he said.
The Starkies called it "a disgrace".
"I walked in there with a healthy full term baby and now he's in here," Mrs Starkie said.
"That can't happen here.
"We're one of the wealthiest places in the world that can't be our standard of care."
The investigation into Tommy's death is known as a severity assessment code 1 (SAC 1), saved for the most serious instances of harm in a hospital.
The coroner is also investigating.
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