LITTLE Caitlin Porter would be enjoying the final weeks of Year 2, getting ready for the holidays and writing a letter to Santa if it wasn't for a series of fatal errors at Ipswich Hospital that led to her death in the maternity ward.
Her mother Rachelle Lind has lived with the guilt associated with her daughter's death and for years thought her baby died of natural causes.
The Coroner's report tells a different story.
Caitlin was born at 3am on May 3, 2007 after a normal pregnancy. In the final two hours of delivery the umbilical cord became wrapped around Caitlin's neck and became very tight over the final 20 minutes before birth.
The paediatric unit registrar responsible for Caitlin "had little paediatric experience" and contacted a paediatric specialist 30 minutes after the birth. It is believed vital tests ordered by the doctor were not carried out.
The doctor took three hours and 20 minutes after first being contacted by hospital staff about Caitlin's status to arrive at Ipswich Hospital.
Medical staff had contacted him for advice 30 minutes after delivery and again at 6.15am when he was asked to attend as the seriousness of Caitlin's condition became evident to the registrar.
The registrar then intubated Caitlin, wrongly positioning the tube (an endotracheal tube or ETT) down the baby's throat.
On arrival at 6.50am, the doctor carried out the blood gas reading he had asked for three hours earlier which showed severe concerns.
Despite two X-rays taken at 7am and 9am which showed the wrongly placed tube into Caitlin's lungs, no one picked up on the mistake until a team from the Mater Hospital arrived at 9.45am.
For almost seven hours after her birth, Caitlin had not been receiving the oxygen support she needed to survive.
A doctor from the Mater team said the first thing she noticed as she entered Caitlin's room was "the clear sound of escaping air", a consequence of the misplaced tube.
The team confirmed this in both X-rays. By this time Caitlin was in a coma with fixed and dilated pupils.
The Mater Hospital team inserted a larger tube with correct positioning and noticed an immediate improvement but her condition again began to deteriorate. They also a recorded a "huge sub-galeal haemorrhage" which had not been identified by the treating team at Ipswich.
Doubt about the correct placement of an ETT can be picked up with a pedi-cap device, which was not available to the treating staff at Ipswich Hospital for Caitlin, but is now.
The Coroner's report into the death stated the "failure by treating staff to initially appreciate the seriousness of (the baby's) condition" may have resulted in "inadequate resuscitation efforts and then, when the seriousness was appreciated, the incorrect positioning of an endotracheal tube prolonged the inadequate resuscitation".
It also states either inadequate respiration or the ongoing loss of blood due to the sub-galeal haemorrhage caused Caitlin's death.
To further add to the list of serious errors in Caitlin's birth, her mother had tested positive for streptococcus, an infection that can cause serious illness and death in newborn babies, a condition which appeared to be overlooked by the midwifery and medical staff.
One of the doctors providing advice to the coronial inquest said many babies that had the umbilical cord around the neck did not develop the degree of hypoxia (deprivation of oxygen) suffered by Caitlin or succumb to a cord tightly around the neck.
Mrs Lind, who was 19 when Caitlin was born, has since had three children, all healthy pregnancies.
It was not until the Coroner's Report was delivered to her late in 2012 that she discovered the extent of the errors in treatment that led to her baby's death.
Caitlin's ashes, a plaster cast of her tiny feet and hands, her teddy bear, clothes, photos and a scrapbook have been stored at Mrs Lind's mother's home, a loving tribute too painful to keep at her own home at Leichhardt.
Mrs Lind said she had blamed herself for the death of her daughter for years until she read in the Coroner's Report in 2012 the disturbing events that led to the death.
After a long battle for justice for her baby, she has approached the Health Ombudsman and will meet with their representative and Ipswich Hospital management tomorrow.
Mrs Lind said Ipswich Hospital had not explained why her baby died and had not offered her any support.
"I want justice," she said. "This should not have happened. For one mistake, you can come to terms with it, but that many mistakes, something is wrong.
"I think it is disgusting. I think they were trying to hide it.
"I'm the one that has to face the hospital to see that it doesn't happen again."
Mrs Lind approached a number of solicitors after receiving the damning Coroner's findings, but could not afford the substantial legal bill her case would attract.
West Moreton Hospital and Health Service chief executive Lesley Dwyer said the circumstances surrounding the tragic incident were the subject of an ongoing conciliation process, following the recent referral from the Health Ombudsman and she could not comment about the specific details of the case.
"Senior West Moreton clinicians are undertaking a detailed review of all the factors associated with the treatment delivered to Mrs Lind and her baby, which will assist with this process," Ms Dwyer said.
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