The parents of a baby who died after substandard care from a midwife say a report into his death brings them no closure.
While the Health and Disability Commissioner's report marked the end of a major chapter in the saga, for Hamilton couple Robert and Linda Barlow it was far from the end of son Adam's story.
The commissioner said the midwife was in breach of the Code of Patient Rights for "severe departures from the accepted standard of care" while dealing with Linda Barlow who was in labour in October 2009.
Far from accepting their situation, the couple strove to ensure changes were made so no other New Zealand mother would suffer a similar experience, pursuing first a coroner's report into Adam's death and now the commission's investigation.
"The alternative way of dealing with it would be full of anger," Robert Barlow said. "I think we have approached it in the appropriate way. We want New Zealand to be able to learn from our experience, rather than be inward-looking."
Being in the media spotlight for such traumatic reasons had been tough.
"It was a huge thing to go to the media. But when you are being told by different organisations that [Adam's death] was just one of those things and to let it go; when you are not being listened to and not being engaged by them, we felt we had to fight - for our family and for the public."
The couple emphasised that they remained concerned that many were yet to acknowledge what had happened.
"It is our express wish that our four-year fight for answers does not end in vain.
"We now challenge health minister Tony Ryall and all health professionals - particularly the midwifery sector - to accept these findings, to learn from them, and put into place a far safer environment for all future mothers, fathers, babies and midwives in New Zealand.
"Our family, including our little boy Adam, experienced and suffered through a frightening and torturous labour . . . that left Linda on life support and resulted in the preventable and devastating death of our much loved baby boy.
"Mr Hill's investigation has been thorough and professional and provides encouraging and insightful comments.
"We believe those findings are fair and the outcomes are proportionate to the areas of the maternity system that let us down the most. We suffered a shocking lack of basic midwifery care with a lack of humanity on October 25, 2009 by a self-employed new graduate LMC Midwife in the community.
"A ruptured uterus is a rare event in a developed country but it was a fully predictable outcome given the substandard level of midwifery care that we endured.
"Despite the devastating outcomes in our situation it is rare for the mother to survive - this was only made possible by the highly skilled medical teams that worked together on Linda to save her life."
- © Fairfax NZ News
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