Newborn’s death in hospital was preventable, court finds

One hospital mistake claimed the life of Jon and Diana Searle’s first child, but a court has found the baby’s death was preventable if staff had noticed the error in time.

On Friday, South Australian coroner Naomi Kereru handed down her findings in the inquest of Bodhi Leo Searle, who died the day after his birth in the Flinders Medical Centre in Adelaide’s south in August 2021.

During labor, staff at the hospital realized they had been incorrectly monitoring Bodhi’s mother’s heart rate instead of the child’s, which quickly revealed he was in fetal distress.

The boy’s cause of death was listed as hypoxic ischaemic encephalopathy due to intrapartum asphyxia – a lack of blood or oxygen to the boy’s brain.

However, a coronial inquest into the incident found that there would have been a possibility of saving the child if the abnormality was detected earlier in labor.

In the early evening of August 29, 2021, Bodhi’s mother Diana Searle commenced the spontaneous labor of her first child, with her partner immediately taking her to the Flinders Medical Centre.

Searle’s allocated midwife was unwell, and another midwife took her place that evening, along with a student midwife that had been “a part of Mrs. Searle’s antenatal journey.”

Throughout the start of the night, her labor “progressed normally with reassuring signs” until 9:56 a.m. (11:26 pm Australian Central Standard Time) when the midwife first noticed something was amiss with the baby’s heart rate.

Searle was taken to another medical ward for CTG monitoring 18 minutes later at 10:14 a.m. (11: 44 p.m. ACST)

However, at 10:48 a.m. (12:18 a.m. ACST), another midwife noticed that “the physical CTG trace had been recording the maternal trace only and took steps to remedy that.”

“Corrections were made to identify the fetal heart rate, which by that time was severely abnormal.”

The court found the “fetal heart rate abnormality went undetected in this time frame and no concerns were raised by any other staff.”

Bodhi was born at 11:38 a.m. (12:58 a.m. ACST), but was “clinically blue and pale, ”and required 18 minutes of resuscitation before breathing his first gasp of air.

Kereru found that efforts to resuscitate the boy after birth were appropriate and timely, “but unfortunately were not enough to reverse the intrapartum damage that had been done.”

Bodhi passed away peacefully at 11:48 p.m. on August 30, 2021 (1:18 p.m. ACST on August 31, 2021).

“Had (the midwife) connected the CTG and reliably monitored the fetal heart rate in the period of time following 10:00 a.m. (11:30 pm ACST), I find that there would have been sufficient concerns with the trace to warrant delivery at an earlier time,” Kereru found.

“If that had occurred between 10:26 a.m. (11.56 p.m. ACST) and 10:36 a.m. (12.06 a.m. ACST) or shortly thereafter, I find on the balance of probabilities that Bodhi’s death would have been prevented. “

She acknowledged that SAHLN had investigated the boy’s death “extensively,” but recommended that all hospitals in the state adopt a new policy to prevent junior staff having to deal with medical emergencies without a senior registrar present.

“(I recommend) that all South Australian hospitals consider the implementation of a policy to be enforced by the Head of the Department, that ensures the most senior registrar onside is appropriately credentialed to undertake complex deliveries independently unless there is a consultant onsite and available.”