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Grieving parents Jenna and Andrew McGregor, who lost their baby boy at just four days old, say more needs to be done to lift the standard of regional healthcare in Queensland.
Last March when Mrs McGregor went into labour she presented at Proserpine Hospital but was moved to Mackay Base Hospital due to a lack of staff.
In 2022, a damning report into Mackay hospital's obstetrics and gynaecology services found catastrophic failings that led to the death of three infants.
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The report promised systematic change, but the McGregors say this has not happened.
After Mrs McGregor was taken to Mackay Base Hospital, she had to wait another six hours for an epidural.
"They were making comments like 'I don't know how this machine works, it's not the same as where I used to work'," she told 9News.
Several hours after arriving at Mackay Base Hospital her contractions were slowing.
An investigation by Queensland Health into the couples' horrific experience stated labour was "not likely to progress effectively without intervention".
"The report is saying there should have been an escalation around midday once she realised, you know, that I hadn't dilated any further in seven hours," Mrs McGregor said.
But another four hours passed before she was given a syntocinon drip to try to increase labour again.
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Queensland Health's report stated that at this point in labour "there should be a transition to obstetric-led care" and "there is strong potential that syntocinon has further contributed to foetal stress leading to decompensation (organ failure)".
Despite this, the dosage of syntocinon was increased, Mrs McGregor said, and "about 10 minutes later Hugo's heart rate just plummeted".
Finally she was taken to the operating theatre for a caesarean section and put under general anaesthetic. Her husband was made to leave the room.
At 4.32pm Hugo was born, but he was pale and floppy. He was resuscitated and taken to the paediatric ward where he was suffering seizures.
"When I woke up I was straight away told that my surgery went well and I asked what about my baby," Mrs McGregor said.
The trio spent four days together at Townsville Hospital before Hugo died, his catastrophic brain injuries caused by a lack of oxygen.
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"Queensland Health's own report, it states on multiple occasions there was opportunities for earlier intervention," Mr McGregor said.
The report also stated there were "numerous communication issues" and "ongoing poor culture for interdisciplinary respect".
"There seems to be a sense of 'there is enough people in the room' … with limited consideration for 'are they the right people?'" the report found.
"That report finds 34 failings in it on that day, this is not one or two issues, this is systemic, organisational issues at that hospital," Mr McGregor said.
Hugo's death came six months after the health minister declared culture and practices would improve at the Mackay Base Hospital following the damning investigation that revealed failings which contributed to the deaths of three infants.
"It's no better at all when you've got oxygen tanks empty, equipment failures, staff not following processes, no documentation," Mr McGregor said.
He added the reason he and his wife went public with their story is "because the public are being lied to and deceived about the safety of maternity services in Mackay".
"People should be made aware. We're told there's no difference in care from regional to cities and clearly that is not the case."
"How many more babies need to die before they actually make a proper change and actually do what they say they're going to do?" Mrs McGregor added.
In response, the Queensland government said the Mackay Base Hospital is committed to change.
The McGregors' case has been referred to the coroner and the health ombudsman.
The Mackay Base Hospital and health service said it has acted on all the recommendations made in the report, including improvements to training, documentation and communication.
