In June 1999, Shinobu and Shinya Ishii took their 4-month-old son, Mahiro, to a municipally run hospital in the city of Funabashi, Chiba Prefecture, for treatment of bronchitis, and were told he would be released after a week or less of care.

Two days later, the hospital called the parents at 7:10 a.m. to say Mahiro's condition had changed. A doctor told the family the baby suffered cardiac arrest earlier that morning after he was found with his face down over a bag of ice.

He apparently rolled over and suffocated while the nurse was away, the doctor reportedly told the parents, adding, "It was negligence on our part."