A Coroner in Craigavon has found that the death of a baby in the Royal Victoria Hospital was potentially avoidable and was related to errors in the system, judgement and technique.
On 28 October 2014, Kai McElroy died just 14 hours after he was born.
His mother, Amy, was only 26 weeks pregnant when she first felt labour pains.
Concerned, she went to the Royal for a check-up, but was sent home by a junior doctor and was told to drink fluids.
Amy and her husband Joe believe their son's death could have been prevented.
Later that month, on 27 October, Amy felt unwell again and phoned the Royal.
She was told by a doctor not to be concerned - a coroner found that this was a missed opportunity to properly assess her condition.
The pain continued.
At 1 am on 28 October, following advice from a midwife over the phone, Amy returned to the Royal.
After waiting 25 minutes to be seen, due to an error in communication between staff, a midwife and then a junior doctor discovered Amy was in an advanced stage of premature labour and that the baby was lying abnormally.
Amy said: "Our world just went upside-down, this was a premature baby at 29 weeks pregnant."
Baby Kai was then born by emergency caesarean section, in the absence of a consultant obstetrician.
"No mother or father should have to deal with losing a child...it was awful, I can't explain it, it was horrific," said Amy.
The Belfast Health and Social Care Trust carried out a Level One Significant Event Report, which was rejected by the McElroy's.
The Trust then carried out a second Root Cause Analysis report.
It concluded: "This baby's loss was potentially avoidable and related to errors in the system, in judgement and in technique."
- Errors in the system: "Not facilitating prompt senior medical assessment on admission".
- Error in judgement: "Not realising the urgency of the situation and expediting delivery by caesarean section; not informing a consultant at an early stage".
- Error in technique: "Not electing for a vertical uterine incision".
A coroner at baby Kai's inquest in Craigavon agreed with these findings and stressed it's vital that lessons must be learned from his death.
A solicitor acting for the family, Lawrence McMahon, said: "The family welcome the coroner's findings as a clear and public acknowledgement of the tragic events that led to Kai's death. However it is a matter of profound regret and sadness that the loss of Kai's young life was avoidable and unnecessary"
In a statement, the Belfast Health Trust said: "Belfast Trust would like to offer our sincere condolences to Kai's family at this deeply sad time.
"We will fully consider the findings of the coroner and we will take any required actions."
Amy and Joe say the loss of their first child will haunt them for the rest of their lives.