Baby dies one day after being born following blunder where nurses accidentally monitored his mum's perfectly normal pulse for 26 minutes instead of his own 'abnormal' heartbeat
- Bodhi Leo Searle passed on August 31, 2021
- He had an abnormal heart rate
The death of a newborn baby whose 'abnormal' heart rate went undetected for 26 minutes was found to be 'potentially preventable'.
Bodhi Leo Searle tragically passed on August 31, 2021, just one day after he was delivered at Flinders Medical Centre in south Adelaide.
An inquiry, overseen by coroner Naomi Kereru, is investigating the circumstances of Bodhi's death - including an incident where his mother Diana Searle's heart rate was mistakenly monitored instead of his.
Counsel assisting the coroner Sally Giles told the inquest it will later hear evidence from an expert witness that Bodhi's death was 'potentially preventable' if his heart rate was monitored correctly, the Adelaide Advertiser reports.
Bodhi's mother Mrs Searle had a normal pregnancy and went into labour on August 29, 2021 - her 30th birthday - and checked into the hospital at about 5.30pm.
Bodhi Leo Searle (pictured with his parents) died one day after he was born in south Adelaide
She was put under the care of midwife Stephanie Geyer and first-year student midwife Thea Koke after her usual midwife informed Mrs Searle she was sick.
Ms Giles told the inquiry Ms Geyer first noticed something was wrong with Bodhi's heart rate at 11.26pm.
Mrs Searle was taken to the medical ward and hooked up for CTG monitoring at about 11.44pm.
'However, at approximately 12.15am, it was identified that for around 30 minutes the CTG trace had been recording the maternal heart rate and not the foetal,' she said.
'Corrections were made to identify the foetal heart rate, which by that time was severely abnormal.'
The registrar and only obstetrician on the ward said they were 'not feeling confident' to perform a 'complex instrumental delivery on her own'.
However, Bodhi was delivered shortly before 1am without instrumental intervention.
Ms Giles said Bodhi's failing health was 'immediately apparent'. He was blue, pale and scored zero points on his Apgar score - used measure a baby's colour, heart rate, reflexes, muscle tone and breathing.
'There was no evidence of any respiratory effort and there was no identifiable heart rate or pulse present,' Ms Giles said.
Mother Diana Searle went to Flinders Medical Centre (above) on August 29, 2021, where her heart rate was mistakenly monitored instead of Bodhi's
It was a full 18 minutes before Bodhi took his first breath.
He was rushed to the neonatal intensive care unit where doctors found signs of abnormal brain activity.
Bodhi Searle passed at 1.18pm on August 31, 2021.
His autopsy found he suffered hypoxic ischaemic encephalopathy - a brain injury caused by lack of oxygen.
Ms Giles said witness Associate Professor Stefan Kane found Bodhi's death was 'potentially preventable'.
'It was probable that earlier application of the CTG and earlier confirmation of foetal rather than maternal heart rate tracing would have permitted earlier identification of foetal compromise which in turn would have prompted earlier efforts to expedite the birth,' Ms Giles said.
Student midwife Thea Koke was the inquest's first witness.
She said she attached the CTG monitor to Mrs Searle, adding Ms Geyer later adjusted the monitor.
First-year student midwife Thea Koke (pictured outside the Coroner's Court) said Bodhi's appearance after birth was concerning
Ms Koke said there had been 'no extreme urgency' in the delivery room and that she'd placed Bodhi on Mrs Searle's chest before resuscitation efforts began.
'I think everybody saw what Bodhi looked like and straight away was concerned,' she said.
Lauren Gavranich on behalf of Southern Adelaide Local Health Network - which includes the Flinders Medical Centre - apologised for the 'tragic circumstances surrounding' Bodhi's death.
The inquest continues.