Hospital delays 'dramatically reduced' baby's survival hopes
DELAYS in providing emergency care to an expectant mother at a northern New South Wales hospital reduced the chances of the baby living, a Coroner has ruled.
Deputy State Corner Helen Barry led an inquest, at Ballina Local Court in December, into the death of baby Jack Brandao-Magalhaes.
Amylee Brandao-Magalhaes was transferred from Murwillumbah District Hospital to Tweed Heads Hospital late on the evening of January 1, 2014, after a problematic labour.
Three days later, baby Jack died at Brisbane's Mater Mother's Hospital.
In her findings, Ms Barry said Amylee "was faced with a distressing time during labour" and cited a number of delays that "dramatically reduced" the chances of baby Jack's survival.
Ms Barry said the delays included identifying the problem with the decelerations in the baby's heart beat, ordering the ambulance, the transfer to the Tweed hospital, and the delay that arose when Amylee arrived at the hospital because "staff had not been advised of the true nature and urgency of her condition".
The Coroner referred to obstetrician and gynaecologist Dr Andrew Child's expert evidence presented at the inquest in her report.
Mr Child said a comprehensive, multi-faceted birthing unit helped to reduce any risk to a baby's life during labour.
"A birth centre in a hospital with an obstetrics unit, operating theatre and a neonatal intensive care unit where if there is a problem it is very quick to transfer the case to specialist care, improves the safety factor," Dr Child was quoted in the findings.
Ms Barry outlined a suite of proposed changes the Northern NSW Local Health District should implement for its midwives following the inquest.
She called for a review of all midwife policies, guidelines and practices at Murwillumbah District Hospital.
Among her educational measures, Ms Barry suggested a one day, in-person midwifery workshop for the foetal component.
She also promoted the use of technology to enable midwives, even if they were on-call at home, to have access to patient notes from home with a laptop to avoid confusion surrounding the patient's condition.
Finally, Ms Barry requested a compliance audit of all midwifery model of care cases at the Murwillumbah District Hospital from 2015 to date to ensure the current policy guidelines and practices were being followed.
Ms Barry said she didn't intend on making these proposed changes into recommendations in the report after being assured by the Northern NSW Local Health District's legal team these changes would be implemented.
At the conclusion of the report, Ms Barry ruled baby Jack died on January 4 from a number of causes as a result of an unexpected outcome of labour.
A lack of oxygen flowing to Jack's brain, multi organ dysfunction and foetal distress were among the numerous causes of the baby's death.
Ms Barry determined that chorioamnionitis, an inflammation of the foetal membranes due to bacterial infection, and meconium aspiration, the baby's inhalation of contaminated fluid prior to birth, were also causes of Jack's death.