On August 31, 2021, Bodhi Leo Searle tragically passed away 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 that it will later hear evidence from an expert witness that Bodhi’s death was ‘potentially preventable’ if his heart rate was monitored correctly. Bodhi had an abnormal heart rate that went undetected for 26 minutes, which was found to be ‘potentially preventable.’

Bodhi’s mother, Mrs Searle, had a normal pregnancy, went into labour on August 29, 2021 – her 30th birthday – and checked into the hospital at about 5.30 pm. She was put under the care of 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. Meyers first noticed something was wrong with Bodhi’s heart rate at 11.26 pm. Mrs. Searle was taken to the medical ward and hooked up for CTG monitoring at about 11.44 pm. However, at approximately 12.15 am, it was identified that for around 30 minutes, the CTG trace had been recording the maternal heart rate and not the fetal.

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 1 am without instrumental intervention.

Bodhi’s failing health was immediately apparent. He was blue and pale and scored zero points on his Apgar score – used to measure a baby’s colour, heart rate, reflexes, muscle tone, and breathing.

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 1.18 pm on August 31, 2021. His autopsy found he suffered hypoxic ischaemic encephalopathy – a brain injury caused by a 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 fetal rather than maternal heart rate tracing would have permitted earlier identification of fetal 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. 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 was immediately concerned,’ she said.

Lauren Gavranich, on behalf of Southern Adelaide Local Health Network – which includes the Flinders Medical Centre – apologized for the ‘tragic circumstances surrounding’ Bodhi’s death. The inquest continues.

»Newborn baby dies of heart rate in Adelaide«

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