A three-day-old baby was sent home from hospital with what doctors thought was wind only for him to die a few hours later, despite efforts by his frantic mum to give him the kiss of life.
A coroner decided that newborn Fletcher Taylor had died from natural causes, but his heartbroken parents believe more could have been done to save him.
At the inquest into her son's death, Gemma Smith, 35, said she told hospital staff that little Fletcher was grey, grizzly and not feeding properly.
But despite her concerns the maternity unit at Burnley General Hospital, Lancashire, maternity unit believed he was fine and discharged them.
Tragically, a few hours later Gemma was watching TV with Fletcher's father Sean Kennedy when the little boy made a noise in his Moses basket as if he had taken his last breath, she said.
Gemma desperately gave her son mouth-to-mouth and he was rushed into a different hospital but was pronounced dead shortly afterwards.
Returning his verdict, East Lancashire coroner Richard Taylor said: "The loss of a child is always a terrible thing whatever the age of the child, but in four days of life, our hearts go out to you.
"What then occurred after the first 24 hours with Fletcher, as in mum's evidence, was he did well with feeding and sleeping but then concerns were expressed of lack of wee, feeding and sleeping.
"It is very noticeable that none of the health care specialists thought these concerns were worthy of note or delay in discharge.
"I didn't find that it was unreasonable to discharge Gemma and Fletcher. No one suggested there should have been any delay after checks on him.
"The conclusion I have to return is one of natural causes, all we can say is that it was an unknown medical cause, the medical cause of death was not fully established."
But despite the coroner's conclusion, Gemma and Sean say doctors should not have sent Fletcher home.
Recalling the day of his death, Gemma said: "He was grey in colour he just looked poorly. He would only settle if he was upright, he seemed uncomfortable. We had to keep him upright all the time.
"When he was born on the Thursday he was a lovely pink, big chunky baby. On the Saturday he was a totally different baby.
"He had been grizzly all night. He looked a totally different baby. Everyone commented that it was not the same baby. I had a photo of him taken that morning, he was not looking a healthy pink colour he looked grey."
The hearing was told that Fletcher had been born on February 14 last year weighing 7lb 7oz and at 39 weeks after Gemma underwent a Caesarean section, as she had done when giving birth to her two previous children.
Gemma was told by midwife that upon his birth Fletcher looked healthy but he had a low set of ears and a small chin and a fat pad on the back of his neck.
Gemma said: "I was a bit shocked because I have read up on all sorts of things when pregnant and I had never heard of a low set of ears. I asked if it was a problem and she said that he would need to be referred to paediatrician.
"It was only briefly mentioned, when the paediatrician came round to do the checks I mentioned it and he said 'no it's fine - no concerns'.
"Fletcher was feeding fine for the first 24 hours. He was brilliant, he took it every two hours, he was perfect. But he gradually stopped over the next 12 hours. He didn't want to know, by Friday evening he wasn't feeding, he was constantly crying. He was very, very unsettled. He wasn't feeding at all."
The inquest was told Gemma told a midwife her son wasn't feeding but added: "She said that the baby of this size was a bit hit and miss with breastfeeding and to carry on persevering because he had fed.
"I was getting stressed. I thought he must be hungry. They said it was quite normal not to feed they didn't seem concerned. I wanted to breastfeed, this was the first baby who actually took to it."
She added that the nurses put it down to the baby being 'windy.'
Gemma said: "How can I have a windy baby if he has not eaten? I don't remember him passing urine. I told the nursing staff he was wasn't weeing.
"I monitored his nappies, on the 15th I kept three nappies at the bottom of the bed. I asked the midwife to check them, they were bone dry but she said they felt alright and threw them in the bin. All they kept saying, he had wind. That's what they put it down to."
The hearing was told hospital notes claimed Fletcher was passing urine and 'gulping milk.'
Further notes taken later recorded both mother and baby were sleeping following breast feeding and at 3.40am that Fletcher had been unsettled for a few hours. The inquest heard that hospital notes recorded the baby being 'a good colour, clear eyes and skin'.
Gemma was discharged from hospital at 4pm on February 16 and family visited later that evening.
But she said: "Nothing settled him. I sent Sean to go and get some milk. He wasn't feeding, he was still crying lots. We got him a bottle. He didn't take the bottle, he wasn't opening his mouth, he was pushing away. He was a really funny colour."
The couple decided to bath him to try and settle him.
Gemma said: "He seemed to cry less but obviously he was on a downward spiral. It wasn't a cry, it was more of a dull cry, he was whimpering. I thought 'we have cracked it, it seems to be calming down'. We decided to stay downstairs with him that night.
"I could hear him making a noise, all of a sudden I heard him make a noise. I said to Sean to ring the ambulance he has stopped breathing.
"I whipped him up. I was trying to blow into his mouth trying to give him air. I knew from picking him up he had just gone limp."
He was taken to Blackburn Hospital where he died at 3.01am after attempts to resuscitate him.
Neonatologist Dr Chi Ning Mo claimed in a medical examination Fletcher appeared healthy.
Dr Mo said: "I found him to be a well looking baby, he had been reported to be breastfeeding well, he was pink.
"He did have a heart murmur but normal heart sounds, no breathing difficulties, liver not enlarged. He did not look to have any unusual features.
"He didn't strike me as unusual in any way. He cried when he was disturbed but did settle once given something to suck. He behaved as a newborn baby would do'"
Midwife Lola Wild said: "Nobody raised any concerns to me about the baby's colour. After 24 hours they can become paler, it's not uncommo. The only difference I saw was the large fat pad on the back of the neck, other than that he seemed healthy to me and I had no other concerns.
"I have no recollection of Gemma raising concerns about her or her baby. We would advise to save the nappies if parents have got concerns and I don't recall seeing them."
Speaking after the inquest Fletcher's dad, Sean Kennedy 27, said: "If I have another child there is no way I'm going to believe the things they say but I'm sure they won't have this happening again. I hold the staff accountable for this. It is a total disgrace."
More:Baby's First Year
Suggested For You
Get top stories and blog posts emailed to me each day. Newsletters may offer personalized content or advertisements. Learn more