Coroner finds baby's death at Flinders Medical Centre could have been prevented
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Coroner finds baby's death at Flinders Medical Centre could have been prevented

May 31, 2024

A midwife's "fundamental and tragic error" in monitoring a mother's heart rate instead of the baby's during labour should have been rectified earlier, which would have prevented the infant's death, the South Australian Coroners Court has found.

Delivering her findings into the death of Bodhi Leo Searle, Coroner Naomi Kereru identified a series of failings in clinical care and concluded that the infant's death could have been prevented.

Bodhi was born unresponsive at the Flinders Medical Centre and died a day after his birth in August 2021.

Ms Kereru found that Stephanie Geyer, the midwife assigned to care for the baby's mother, Diane Searle, did not adequately monitor readings from a cardiotocography (CTG), despite moving Mrs Searle to a suite for the purpose of monitoring the fetal heart rate.

"It has not been disputed at the inquest that for a period of close to 30 minutes after the CTG was first connected, the CTG was tracing Mrs Searle's heart rate, and not Bodhi's," Ms Kereru said.

"This was a fundamental and tragic error."

The inquest heard that it was not until Ms Geyer requested a break that another staff member took over and quickly realised the mistake.

"Ultimately, Ms Geyer was responsible for the care of Mrs Searle and during that care there was evidence of significant foetal distress which did not appear to have been appreciated by her at all, or until it was too late," Ms Kereru said.

Ms Kereru found Ms Geyer then did "not communicate her concerns" or make sufficient follow-ups about the need to get assistance from a senior doctor.

Ms Kereru said that if the errors had been picked up earlier there "was sufficient time to have corrected it".

"Had Ms Geyer taken this course of action, there was an opportunity for the escalation of care … for Bodhi to have been delivered in sufficient time to prevent the intrapartum hypoxia from which he died," she said.

"I am of the view that had SALHN (Southern Adelaide Local Health Network) had better systems in place for ensuring a CTG was properly displaying fetal heart rate and was on display in the nurses' station, and had there been a senior midwife dedicated to watching that CTG in the nurses' station, it is likely that the impact of Ms Geyer's individual errors in relation to the CTG would have been minimised or even averted."

The court heard that at the time of Bodhi's birth, a first-year obstetrics registrar, Dr Elizabeth Lindner, was rostered as the most senior obstetrician onsite.

A more senior obstetrician, Dr Kate Gowling, was rostered as on the on-call consultant obstetrician from home, 25 minutes away.

The inquest heard Dr Gowling was ultimately called in and delivered Bodhi, because the onsite obstetrician did not have the experience required to carry out the complicated urgent assisted delivery.

Ms Kereru noted that both Dr Lindner and Dr Gowling acted appropriately and were not responsible for the rostering issues.

"It is well-known in obstetrics that a low-risk birth can become high-risk quickly," she said.

"That is exactly what occurred in this matter."

Ms Kereru said Dr Lindner "did not have the skills required" to be the most senior obstetrician onsite on the evening of Bodhi's birth.

"Concerningly, Dr Lindner gave evidence that after Bodhi's death, she made it clear to her superiors that she did not feel comfortable being rostered as the most senior doctor on duty overnight without an on-call consultant remaining onsite," she said.

"However, that situation repeated itself on occasions prior to her leaving FMC [Flinders Medical Centre] and taking a residency at an interstate hospital."

Ms Kereru recommended that all maternity hospitals in the state consider implementing a policy ensuring the most senior registrar onsite is "appropriately credentialed to undertake complex deliveries independently unless there is a consultant onsite and available".

The court heard evidence that the health network planned to have a "document for each of the registrars to be made available to the consultants, so the consultants can ascertain for themselves whether they should be on or offsite when rostered on as a consultant with a particular registrar".

Ms Kereru said that would be an "unrealistic expectation which places an uncomfortable onus on the registrar".

"It is difficult to see how this would be a substantial improvement on the process that was in place at the time of Bodhi's birth," she said.

"Particularly if a complex emergency arose, as there would be a delay waiting for the offsite consultant to arrive."

The court heard that the hospital had "extensively" investigated Bodhi's death and implemented some changes, including a "check system" to ensure CTGs were properly connected and monitored, and displayed at the nurses' station with an "allocated nurse to monitor the CTGs at all times".

The court heard Mrs Searle felt meetings with hospital staff after Bodhi's death were "far from open and appeared to her to be an attempt by the hospital to withhold information".

In an affidavit given to the court, Mrs Searle said she and her husband were told that SALHN had "absolutely no idea what happened" and the error with the CTG was not mentioned "even though it was in my medical records".

The court heard that a letter to Mrs and Mr Searle stated, "We are at a loss as to why Bodhi was so unresponsive at delivery and ultimately passed away".

"While awaiting the results of the post-mortem it is accepted that there was a level of discernment in not delving into possible theories as to Bodhi's cause of death," Ms Kereru said.

"However, to positively state that SALHN was at a loss as to why Bodhi was so unresponsive at delivery and ultimately died was simply incorrect and inappropriate to say in the circumstances."

The divisional director of the health network, Dr Dylan Mordaunt, was asked to comment on that during the inquest.

"He told the court that if the hospital had known that there had been an error at the time of the meeting with Mr and Mrs Searle, then a letter expressing 'We are at a loss as to why Bodhi was so unresponsive at delivery and ultimately passed away' was inappropriate," Ms Kereru said.

In a statement, SA Health said its "sincere condolences go to the family of Bodhi Searle".

"We are reviewing the Coroners' findings handed down today and will consider the recommendation," the statement said.