Jamie Hare was excited about watching the birth of his fourth baby. On a cold day in June 2010, the plasterer put on a gown at Latrobe Regional Hospital and waited to be called into the operating theatre for his partner Linda's caesarean.
Linda was glad he was there, too. Cursed by a small pelvis, she had previously been alone when delivering their three daughters by caesarean and wanted Jamie to hold her hand.
But while hospital staff busily prepared for the surgery, something changed and Jamie was left in a room nearby. He thinks they forgot about him.
Over the next half hour or so, he anxiously read the same newspaper twice while waiting to hear more. Then came a "code blue" through the hospital speaker system. It was followed by another one, and another one.
A perfect baby girl had been born, but in the two hours since he'd parted with Linda, she had suffered torrential bleeding from her womb. The haemorrhage was so bad, her heart had stopped twice.
The bleeding was caused by the placenta being stuck to her uterus, and not detaching like it usually would after birth. This condition, known as placenta accreta, is often linked to scars on the uterus due to previous caesareans.
Because of her history, Linda Parker, a healthy 39-year-old, had an estimated 40 per cent chance of the potentially life threatening problem. And yet none of the doctors caring for her during her pregnancy had investigated the possibility so they could prepare for it.
An anaesthetist resuscitated Linda that morning with dozens of units of blood, including some that were not her blood type because the hospital ran out. An obstetrician also tried to remove her womb to stem the bleeding. It didn't work and he accidentally nicked her bladder in the process.
The team packed her abdomen with gauze and sent her in a helicopter to Monash Medical Centre for more specialist treatment. She continued to bleed on the way.
Jamie says that when Linda arrived in Melbourne, she was unrecognisable. Her head was so swollen that her blue eyes had seemingly disappeared into her face. Within 12 hours, one of her legs had turned black due to the catastrophic blood loss, prompting doctors to discuss an amputation.
Over the next week, Linda lay unconscious in the intensive care unit. During this time, her three older daughters, then aged 20, 16 and 13, learnt to feed their new sister, Alicia, who spent time resting on her warm mum.
At one stage, Jamie gently prised Linda's eyes open in case she could see her baby. He says the machines attached to her went 'berserk', giving him momentary hope the two had connected.
But 11 days after the birth, doctors said Linda's brain was so damaged she could not go on. A machine helping her breathe was turned off. She died a short time later.
In 2015, a coronial review said a paperwork mix-up contributed to Linda's condition not being diagnosed sooner. None of the forms for ultrasounds during her pregnancy included details of her previous caesareans. Such information would have prompted a more thorough investigation of placenta accreta.
An obstetrician told the Coroners Court that, had this been diagnosed earlier, she would have been transferred to Melbourne for more specialist care to give birth.
The court heard that Andre Paul Hugo, one of the obstetricians who cared for Linda during her pregnancy had also failed to make a "basic association" between the implications of her history and hints of an abnormal placenta while planning the birth.
After Linda's death, he moved to Western Australia. In 2015, the Medical Board of Australia suspended him while investigating claims he was partly responsible for a stillbirth of a baby aged 40 weeks at Rockingham Hospital.
During the investigation, Dr Hugo surrendered his medical registration. He was later found guilty of misconduct for his management of the birth, and for failing to keep proper clinical notes. He was reprimanded, fined $5000 and ordered to pay costs of $3500. He has since left Australia. It is unclear where he now resides and whether he's still practising medicine.
Jamie and his four daughters sued Dr Hugo and Latrobe Regional Hospital. Their lawyer, Nick Mann, of Slater and Gordon, recently settled the case with a confidential pay-out.
Nearly seven years on, Jamie and his daughters remain devastated by the loss of a friendly, no-fuss woman who preferred tracksuit pants over dresses and who loved 80s music. Every year, they put her name on Christmas cards to others as though she's still here.
Jamie says he and his daughters were gutted to learn that Dr Hugo had gone on to be implicated in a stillbirth. It makes them wonder if other cases are yet to come to light.
Spokespeople for Latrobe Regional Hospital and the medical board would not comment on whether Dr Hugo was involved in other medical negligence claims. Nor would they say if concerns about him had been reported to the board before 2015.
If nothing else, the family hopes Linda's story will prompt other pregnant women and their doctors to be more careful in future.
"It breaks my heart that my youngest daughter will never know her mother," Jamie says. "This should never have happened".