A woman who lost two babies, born prematurely at Canberra Hospital, says her trauma was compounded by the indifference, lack of compassion and care she experienced.
In a submission to the inquiry a woman, who asked to remain anonymous, said she gave birth prematurely to twin boys at the hospital.
Sadly, they both died.
Her experience ultimately led her to leave the ACT.
She said she was not categorised as high risk - despite having twins via IVF and being older than 35 - throughout her pregnancy.
The woman said in the weeks before going into labour, she came to the emergency department twice with pain she said was an 8 out of 10. No scans were taken during the visit and she was sent home.
She wonders what could have been if her signs of pre-labour were picked up at the time.
She was admitted to Centenary Hospital for Women and Children in 2015, giving birth to twin boys at 24 weeks and three days and 25 weeks. Both died, 12 hours and 36 hours respectively after birth.
The woman said kindness and compassion was often missing during her stay and she felt she had no say in the decisions made about her care.
"I am a pretty amenable person and defer to experts, yet I often felt treated by doctors and nurses/midwives at best as a body and at worst as a nuisance," her submission read.
"I was a body and not a person. I recall in the birthing suite, sometimes hours would go by before a nurse would see me.
"Often, I bled into the plastic disposal mat and would sit in blood until I was able to move, or my mother visited and I could get another one to replace it. "
She said the only time she felt her sons were shown true care was when an NICU midwife took it upon herself to take countless photos of them while she was away from them.
The woman said she was shocked when she later discovered the "baby doctor" left the hospital one hour after her first son was born extremely prematurely and had to be called several times for advice on what to do about extracting blood for testing.
Her son died from bleeding due to pricks to his skin to extract blood and a suspected brain haemorrhage, the submission said.
The haemorrhage was never proven as the scan was unavailable, she said.
She said the trauma of giving birth to and losing two children in 10 days was horrific. But this pain was compounded by the lack of care, compassion and indifference she experienced, the submission read.
"There is no way that I could return to that building and the organisation that runs it. I hope for the sake of other parents that things have changed," she said.
She also questioned whether her race, as a non-white woman - played a part in her treatment and the disregard for the seriousness of her pain.
The inquiry was launched after midwives and staff at Canberra Hospital penned an anonymous letter to the government saying patients' lives were being put at risk due to understaffing and poor management.