The ACT’s Coroner has found failures in treatment during and after birth led to the death of a newborn baby in the neonatal unit at the Canberra Hospital in 2017.
Warning: This article contains details that readers may find distressing.
The boy, known as Baby X, suffered serious injuries during his delivery.
Coroner Ken Archer has detailed how doctors differed over which way the baby’s head was pointing during labour.
He said there were attempts to help the boy through the birth canal, using a suction cap and forceps.
Both were unsuccessful.
“[One doctor] determined that a caesarean section was required,” Mr Archer wrote in his report.
He said even that proved difficult.
“It is highly likely that Baby X was deprived of oxygen for a period during this process,” his report said.
‘Deprived him of a chance of survival’
The boy was resuscitated in the neonatal unit (NICU), and it took 14 minutes for him to breathe spontaneously.
Baby X was diagnosed with hypoxic ischaemic encephalopathy, which means there has been a brain injury from lack of oxygen and blood flow.
“Significantly, during the birthing process Baby X suffered severe injury to his scalp, causing a large subgaleal haemorrhage,” Mr Archer said.
But Mr Archer said it wasn’t detected until that afternoon when Baby X went into cardiac arrest.
In his report, Mr Archer said only then did Baby X start to receive fluid transfusions, including blood products, which were appropriate treatments.
Despite these efforts an MRI scan the next day revealed a poor prognosis, with serious brain injuries, and Baby X died the following day.
In his findings Mr Archer said it was impossible to say if the delay in recognising the subgaleal haemorrhage was the difference between Baby X dying or surviving with a level of neurological damage.
Mr Archer found the vacuum delivery had been appropriately attempted, but there were inadequate steps to determine the foetal position, and the vacuum cup was positioned incorrectly.
But he found even if the vacuum cup had been properly placed, he did not accept that would have necessarily led to a successful delivery.
He said he also accepted expert advice that the treatment of Baby X in the neonatal unit had been inadequate.
“The failure to provide him with adequate care after his birth deprived him of a chance of survival,” Mr Archer said.
In his recommendations, Mr Archer also noted that there had been a failure to make adequate scalp observations after Baby X was born.
He said that a matrix for such measurements had been developed but not implemented at the time.
Mr Archer said it is now in force as well as a mandatory consideration about whether ultrasound is required to determine a baby’s position.
Parents of Baby X requested public hearing
The report said Canberra Health Services acknowledged that the treatment of Baby X was inadequate.
The death of Baby X was not initially reported to the coroner.
The first report was in 2019 when Canberra Health Services wrote to the then Chief Coroner.
But the inquiry did not go far.
Mr Archer said the inquest was among a significant collection of older cases handed to him when he took on the role two years ago.
In the end Mr Archer delivered his findings with no public hearing, despite a request by the parents of Baby X.
