A couple whose baby died in their arms say they were robbed of precious time with him after being told he was already dead.
Ellie and Chris James, of Haverfordwest, said they were told their son was stillborn in May 2016.
But Callum, born at Glangwili hospital, was still alive and died in their arms.
The Ombudsman said they had been through a “heart-breaking experience” and Hywel Dda health board has agreed to apologise.
In a damning report, Ombudsman for Wales Nick Bennett, highlights a series of distressing failings, including delays in treatment, which he said meant the couple “will never know” if their son could have survived.
The report upheld complaints against Glangwili, Carmarthen, and Withybush hospitals.
The couple spoke to BBC Wales about the heartbreak of holding their newborn son.
“When we held him he was actually still gasping at the time, we were told that it was a spinal reflex – we now know that he was still alive,” said his mother, Ellie.
“We cherish the moment that we had with him, to be able to hold him, but if we had known he had been alive at that point we would have had a small comfort in knowing he was in our arms, that he passed away while being cuddled.”
Ellie said she started having pains during her delivery, but was told it was normal and the Ombudsman found her concerns were dismissed by medical staff.
After he was delivered he was taken away by nurses who started resuscitation on him. The couple said they thought he would live after hearing him struggling for breath.
“We knew by that time he wasn’t very well, but we didn’t think he would pass away – not in a million years,” said Chris.
The couple, who have two other children, Ragen, seven months, and Grace, three, said that about 35 minutes later a consultant came over to tell them their son was dead.
They said they were never told by doctors that they were planning to stop resuscitation. It just stopped and their son was placed in their arms.
“That was a shocking point for us, from having a perfectly healthy baby to all of a sudden being told there is nothing they can do for him,” he said.
The couple said knowing Callum was still alive as they held him in their arms was “heartbreaking” as they could have taken the chance to christen him, rather than the blessing he had.
“We feel like we were robbed of our final minutes with him because we weren’t told he was alive at that point – it’s heartbreaking to know we missed that,” said Ellie.
The couple said their older daughter Grace has given them strength making them smile even in the darkest times, but said they would never get over the pain of losing Callum.
Ellie said: “I don’t think this is something you can move on from, you learn to sort of live with the pain, it doesn’t get easier, in some ways it gets harder.
“We can never have a picture of our three children together, it is very hard looking at family pictures knowing that one child is missing.”
A complaint from the couple to the health board was upheld by the Ombudsman, who pointed to a “whole host of failings” including that their son’s death had been incorrectly registered as a stillbirth rather than a neonatal death.
Mr Bennett said the board also failed to undertake appropriate tests on the mother and baby after the birth which affected its investigation into the cause of the death and caused “significant worry and distress to the family”.
He said he hoped that the ruling would provide “some small comfort” to the family.
The Health Board agreed to implement all of the Ombudsman’s recommendations including providing the couple with an apology.
They will also pay £4,500 in recognition of the distress, delay and uncertainty she experienced, and to change the baby’s status from “stillborn” to “neonatal death.”
The board’s chief executive Steve Moore said: “We are sorry for the failings in care identified and we have written to Mrs James to apologise. We accept the recommendations the Ombudsman has proposed.
“Our staff have already undertaken many improvements to our service as we continue to strive to improve the care we offer.”