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Sonya and Youssef Ghanem went to Sydney's Bankstown-Lidcombe Hospital in July 2016 expecting to bring home a little brother for their three children.
Instead, their baby John died just under an hour after he was born.
Their grief was compounded when they learned their newborn had been ventilated not with oxygen, as the operating theatre's gas outlet was labelled - but instead with nitrous oxide.
An inquest has begun into John's death and the 'shocking chain of events' at the hospital that led to it.
Sonya Ghanem arrived at the hospital on the morning of July 13, 2016 after her waters broke, counsel assisting the inquiry Donna Ward said in her opening address on Monday.
Her obstetrician decided she should have an emergency caesarean section because of a risk of infection and her baby's slowing heartbeat.
Sonya and Youssef Ghanem went to Sydney's Bankstown-Lidcombe Hospital in July 2016 expecting to bring home a little brother for their three children. Instead they left in unimaginable grief
Fatefully, she was wheeled into the hospital's Operating Theatre 8. John was delivered there at 11.54am.
He gave a weak cry but was not breathing properly. There was a loose loop of cord around his neck.
Doctors began desperate efforts to save his life, first rubbing him with a cloth, then
