Robert Kane killed himself on his 36th birthday after his newborn son died of pneumonia as the doctor "losing" her notes
Baby Mason Kane was only three weeks old when his mum Sandra Charles noticed that he was short of breath, had sticky eyes and a rash on his bottom.
As any normal parent would, she immediately took him to their local GP to be check over.
Dr Nandini Das, 55, checked him over and gave him the all-clear.
Five days later, baby Mason was dead.
Sandra was engaged to Mason's father, Robert, and they became parents to little Mason in June 2014.
He was born two weeks early by caesarean, and had to stay in hospital for three days before the hospital allowed Sandra and Robert to take him home.
Three weeks later, Sandra, from Barrow-in-Furness, Cumbria, noticed that he was becoming a little poorly, so her and Robert took Mason to see their local GP, Dr Nandini Das at Duke Street Surgery on 24 June.
But, infuriatingly for Sandra, Mason was given the all-clear by Dr Das, who told them to treat Mason's sticky eyes with shampoo.
And - because Mason was not yet registered at the surgery, Dr Das proceeded to write down her notes of the visit on a sheet of paper.
Sandra said: "Dr Das checked him over and told me to put shampoo in his eye to help with the problem but I refused to do this and asked for a prescription instead.
"She didn't examine his bottom and she listened to his chest but told me it was all clear and dismissed any concerns I raised - I left the surgery feeling angry.
"Mason wasn't taking his bottle and he seemed agitated and as we were going to bed and Mason looked really peaky and pale - to me he didn't look like the same baby. Myself, Rob and Mason all slept in the same room and he went to sleep."
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Unfortunately, Dr Das then lost the note, failing to put the details of the appointment into the computer database.
Only five days after the appointment, Mason was rushed to hospital when he stopped breathing and his face turned blue.
Sandra explained what happened next: "The following morning I gave him a cuddle and gave him his bottle and then I put his Moses basket on its stand and sat on the bed watching TV. I heard a strange gurgling noise and when I looked over at him his lips were blue.
"I grabbed the baby and ran downstairs screaming and passed him to Rob and in distress he went into the street screaming for help."
A neighbour tried to revive the baby before he was taken to hospital, but he had to be transferred to Royal Manchester Children's Hospital where he devastatingly passed away.
He had died of multiple organ failure and tests showed he had a blood clot on his lung - and he was suffering from acute pneumonia.
At an inquest, Dr Das was criticised by the coroner, but said that there was no way to know whether Mason's symptoms discussed in the appointment were linked to his death.
Dr Das then explained to the hearing that her practice had now taken extra steps to make sure that records from unregistered patients were organised more effectively.
She said: "As a newborn baby, Mason was not registered and so was not on my computer, so I made a hand-written note of the appointment. However, that note somehow got lost before I could put it into the system.
"I remember that he was bought in with sticky eyes and I advised what should be done. This did not concern me as I have seen this kind of symptom before. I took a swab and sent it off for analysis and it was clear.
"I don't recall the mother mentioning the breathing or problems with the bottom. I know that I would have observed the breathing and I remember that the baby was awake and alert and didn't have any trouble taking the swab.
"If I had any concerns about the baby's breathing I would have referred him to hospital and I would not have let him leave the surgery."
However, Coroner Nigel Meadows said: "I think I prefer the account of Miss Charles. If Dr Das had a contemporaneous record that would be persuasive but she didn't.
"Miss Charles took Mason to her GP practice and it seems he was not registered and there was some time she had to wait. She says during that consultation she raised four issues but prior to this Mason had been feeling well.
"She said he had some unusual inhalation of breathing and that was one of the issues raised with Dr Das. It is unfortunate that although the doctor did a written manuscript of the conversation but this was overlooked and no record was made.
"It was only on the 8th of July that Dr Das became aware of the death of Mason and that there wasn't a record. The General Medical Counsel state that doctors must make a reliable and contemporaneous note of consultations.
"No definitive reason can be ascertained for what happened to Mason. He had pneumonia but that can develop very quickly and on his arrival to hospital there was no evidence of any infectious illness. Sometimes babies can be born with an abnormal heart rhythm and there is no way of detecting this and this can happen to anyone."
In yet another cruel blow for Sandra, her fiancé could not cope with Mason's death and took his own life.
Robert was so heartbroken at the death of Mason that he killed himself on his 36th birthday - Valentine's Day.
An earlier inquest found that Robert's death was given a verdict of drug-related death after he took a fatal drink and drugs cocktail of sambuca, rum and vodka, along with diazepam and a prescription drug for epilepsy at their home.
The hearing was told he had been "struggling" to deal with the loss of his son.
Our thoughts are with Sandra, who has not only lost her newborn baby, but her loving fiancé too.
Have you or a loved one ever had to deal with the loss of a baby? Let us know over on Facebook and Twitter.
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