Tragic mix up: Hospital staff confused newborn with her dead twin.

A mix-up in a Brisbane hospital cost a premature baby up to four crucial minutes after staff confused her with her dead twin, a coroner has found.

Elsie Robertson was delivered by caesarean section in October 2012, after her sibling died in their mother’s womb at 23 weeks.

During the pregnancy, she had been labelled “twin two” while her twin was referred to as “twin one”, but when she was born, showing no signs of life, she was handed to the nurse with the words “twin one”, the Courier Mail reports.

Deputy State Coroner John Lock found obstetrician Dr Len Yared had simply meant Elsie was the first baby to be delivered.

She was moved to a open cot by the nurse who was soon told by a midwife, “I’m sorry but this is the baby you should be resuscitating.”

Once staff began to resuscitate Elsie she “responded reasonably quickly”, Mr Lock said, surviving for ten hours before her life support was switched off because of a “poor prognosis” and serious brain damage.

She was found to have died from E.coli sepsis, transferred to her by her twin.

Medical experts believe starting resuscitation immediately would not have saved the newborn’s life, but Mr Lock said there was still an “unreasonable delay” in giving antibiotics to the baby.

“However, the expert opinions were consistent in that they considered such delays were minor and/or insignificant in respect to any contribution to the ultimate cause of death,” he said.

The Mater Hospital will implement several recommendations to ensure a similar mistake is not made in the future.