Ms Guillaume arrived at PMH late on August 1, 2022, at 39 weeks and three days pregnant. Ms Guillaume reached the operating theatre entrance at about 4.10am. He said Dr Clare and Dr Foulkes-Mackey acted promptly and did all they could to get Ms Guillaume into the operating theatre. Medical staff began chest compressions and a resuscitation effort, but the baby died later that morning. The hospital’s COVID-19 protocols were also not produced, despite the COVID test contributing to the period Ms Guillaume spent waiting outside the operating theatre.