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The body of a baby was left in a morgue in a Queensland hospital while its parents thought it was undergoing an autopsy after being born prematurely.
In a major bungle, Queensland Health said the disturbing incident has sparked a major overhaul of protocols.
Penelope Gage was born at Townsville Hospital on October 12 at 28 weeks and spent two weeks in neonatal intensive care before passing away.
Her parents were keen to get an autopsy to see if there were risks to future pregnancies.
She was supposed to be flown to Brisbane but never left the morgue.
Parents Haylee Webber and Doug Gage assumed the autopsy had happened when their funeral director picked up Penelope for a cremation ceremony.
But she was lying in the morgue, forgotten by hospital staff.
Her mother said her nightmares haven't gone away since she found out what happened.
Doug Gage and Haylee Webber look at a photo of their baby girl
Penelope was born 12 weeks premature and spent a fortnight fighting for her life in Townsville Hospital before dying of sepsis
Penelope Gage was born at Townsville Hospital and spent two weeks in neonatal intensive care before passing away
'We had our daughter for two weeks and we were told she was doing well in NICU then she died of sepsis. We never expected to lose her, never mind this harrowing ordeal,' she told Courier Mail.
'One minute we are holding her to our hearts, so grateful for a beautiful daughter who was looking more and more like a healthy baby every day and the next we are in the depths of hell.'
Queensland Health told The Courier-Mail they apologised to the parents, saying it didn't deliver 'the best care possible'.
'Unfortunately it (best care) did not occur on this occasion. While we are limited in what we can say due to patient confidentiality, we have apologised for what happened and we continue to engage with and support the family,' a spokesperson said.
Changes have since been made to make it easier for staff managing autopsies.
Despite the changes, Penelope's parents still claim they have been left in the dark as to why they lost their daughter.
'We need to know why a premmie baby that was being monitored in intensive care was able to develop sepsis that went undetected,' Ms Webber said.
Townsville Hospital and Health Service chief executive Kieran Keyes said in a statement: 'Townsville University Hospital is conducting a clinical review into the obstetric care of Haylee. We have also referred the care of both Haylee and Penelope to the Townsville University Hospital perinatal morbidity and mortality committee.'
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