KEY POINTS:
When Varian Wi junior celebrates his sixth birthday on Thursday, there will be two names written on his birthday cake - as there have been every year since he was born.
The other name is Zephaniah, Varian's twin sister, who lay beside him for 12 days, holding his hand, before parents Sharlene Kavetoa and Varian Wi made the agonising decision to turn off her life support and let her slip away.
The past week has been traumatic for the couple following revelations about Dr Ramesh Vasant.
The South African-trained medic's decisions during Zephaniah's birth were labelled "risky and inappropriate" by Health and Disability Commissioner Ron Paterson.
The Accident Compensation Corporation found Vasant made mistakes in that and two other births in 2003, when both babies were born brain-damaged.
"I was totally shocked that he had done it not just to us, but to other families," Kavetoa told the Herald On Sunday. "It just reopened all those old wounds."
Wi, sitting on a stool nearby, is less composed. Clearly angry, with tears welling in his eyes, he said simply: "We were robbed."
Kavetoa recalled how she was rushed to Whakatane Hospital to give birth to her twins, whom she had already named.
She spent more than 12 hours in labour, finally requesting an epidural to cope with the pain. It was never administered. The anaesthetist was called, but never arrived.
Varian was born just before midnight, but there were further complications and Zephaniah was delivered by caesarean nearly an hour later.
Kavetoa believes the delay ultimately caused the death of her daughter, on April 2, 2002.
Paterson found the failure to get an anaesthetist to the hospital caused an "unacceptable" delay.
At the family's small home in Kawerau Varian chats about his sister as if she is still with him, showing off the few photos the family has of little "Zephy".
Mum Sharlene Kavetoa thinks her energetic, smiling son has an almost "psychic" link with his dead twin.
She lifts a tiny pink cardigan from a cardboard box. It is the one worn by Zephaniah in the photos.
"I think of her constantly. I think, what if there was two of them? What would she have looked like? Would she be different?"
Another box is full of reports, letters and documents from their six-year battle for compensation and recognition.
Among them is a letter from Kavetoa to Paterson, describing the decision to turn off Zephaniah's life support. It is almost unbearably sad.
"We held Zephaniah in our arms as she was removed from the ventilator. After 45 minutes of our darling daughter fighting for her life, she took her last shuddering breath.
"For any parent to have to watch their baby struggling to simply breathe is unimaginable so I will not describe how that was.
"The gut-wrenching feelings we felt when we finally got to travel home as a family were extreme.
"We travelled home together but only one of my babies was alive in my arms."
The couple have won apologies from Bay of Plenty District Health Board, the hospital, an anaesthetist and Vasant.
But Kavetoa is unimpressed.
"Sorry is not good enough. There have been all these investigations and nothing has come of it.
"He stuffed up three births in 18 months. He shouldn't be delivering babies at all. I want him to be kicked out of the medical profession."
The Herald on Sunday can this week reveal the Medical Council - responsible for monitoring doctors - waited a year before responding to warnings about Vasant.
The council was first contacted about Vasant in October 2003, when the ACC raised concerns about his care of Zephaniah.
But they ordered a review of his competency only after receiving Paterson's report on Vasant's role in Zephaniah's death in July 2004.
He was highly critical of Vasant's handling of the incident and his apparent ignorance of the hospital's protocols.
"Dr Vasant's clinical decision to rupture the membranes in the absence of an anaesthetist... was risky and inappropriate," he said.
The council said it was aware of concerns about Vasant from "several sources" and finally ordered a competence review in October 2004.
Three months later Vasant left for Australia as the inquiry was about to start and worked there until being stood down just over a week ago.
A spokesman said the council acted as quickly as possible over all three botched births.
He said the Health Practitioners Competence Assurance Act prevented it from taking action until complaints to the Health and Disability Commission had been resolved.
"Doctors must have the opportunity of responding to council. If the council does not provide adequate opportunities this may well prolong the process through appeal."
The delay has prompted Paterson to call for changes to the legislation, which is under review. A submission tables his wider concerns, including a fear that doctors and their lawyers are delaying competence reviews through legal channels.
Vasant's appeal against the ACC's findings was dismissed by Judge Martin Beattie in the Auckland District Court this month.
The Melbourne hospital where Vasant has worked since February 2005 stood him down from caring for women in labour.
Paterson has renewed calls for transtasman authorities to share more information about competence and formal inquiries into medical mistakes.
Zephaniah is buried at Kawerau cemetery, a sheltered, leafy haven in a bleak landscape of hills clear-felled of pine trees. Her grave was paid for by "a couple of thousand dollars" from ACC, observes Wi bitterly.
The couple have since had a daughter, now four years old, but there will still be an empty place at the birthday party this week, despite the extra name on the cake.
"She will always be a part of this family," says Kavetoa.
