A mother has relived the horrific moment she gave birth to her severely-premature baby in the toilet of a labour ward - despite medics declaring her medically fit to go home just hours earlier.
Cerys Blackwell, who only saw her son Bobby James for moments before he was taken away and pronounced dead, said the traumatic ordeal still haunts her to this day.
She was 23 weeks pregnant when she gave birth at Prince Charles Hospital, Merthyr Tydfil, on April 15, 2017.
An independent review into maternity services, which she opened up to, at Cwm Taf Morgannwg University Health Board found a catalogue of serious failings 'from board to ward'.
Cerys Blackwell gave birth to her premature son Bobby James at 23 weeks in the labour ward toilets despite being told she was fit to go home. Behind her in this picture is a sign with Bobby's name and the words 'Mammy' and 'Daddy'
Mrs Blackwell said she was only allowed to see her son for a few moments (pictured) before he was taken away and pronounced dead
'I felt like I didn't really matter [to the staff] because we were not at term. Some of the staff were great and supportive - but many did not care.
'I did not feel safe even though I was in hospital, and I would fear the weekends and the nights when I knew the wards were understaffed.'
Mrs Blackwell, who had a whole host of complications and needed multiple stays in hospital throughout her pregnancy, was admitted to Hospital on Thursday, April 13, because of concerns about bleeding and a blod clot.
She said the doctor wanted to run tests but 'like on other occasions, other staff took over and I don't feel like they observed me as well as they should have'.
'Samples went missing and results were not interpreted correctly during changeovers,' she said.
She opened up about her experience at Prince Charles Hospital, Merthyr Tydfil, at an independent review into Cwm Taf Morgannwg University Health Board. (Pictured) Mrs Blackwell and her second son Noah George Blackwell
Mrs Blackwell and her second son Noah throw flowers into the sea on the second anniversary of Bobby's birth in Southerndown
Despite the staff initially treating her situation with caution and even giving her a private room, two days later on April 15 a consultant told her she was able to go home.
She said: 'The previous day I was told to only get up out of bed to use the toilet due to my water leaking and blood loss, so I was a little taken aback at being told I was medically fit to go home.
'I asked about my leaking fluid, my cramps and regular contractions throughout the Friday morning and my severe back pain.
'She could see I was nervous, but she said to go home and take things easy. She said with it being a bank holiday weekend there was not a lot they could do anyway.'
After much deliberation - and feeling very unsteady on her feet - she called her father for a lift home to Ystrad Mynach.
But as soon as they arrived at their house, Mrs Blackwell said she felt 'a pop' in the centre of her pelvis.
'I could see puddles on the floor and my jeans were wet. My dad called the labour ward straight away,' she said.
The tag used for Bobby James at the hospital. Mrs Blackwell said he was taken away moments after the birth and pronounced dead
When they got to the labour ward, Mrs Blackwell said the staff 'laughed' at how anxious her father was.
'The midwife kept referring to how she had never seen anyone in such a state. They suggested that he was overreacting.'
Before long her mother and husband, Chris Blackwell, arrived at Prince Charles Hospital.
'The contractions became more painful. I became very hot and the midwife got me a fan to cool me down. She also got me a pad as I was bleeding again. But