No individual staff member was responsible for the death of a newborn who suffered fatal head injuries during an emergency caesarean at Queensland’s largest hospital, a coroner has found.
Born in June 2014, Nixon Tonkin never breathed on his own after being delivered at Royal Brisbane and Women’s Hospital.
An inquest into his death heard a midwife was asked to carry out the emergency procedure she was not trained to do in a bid to free Nixon’s head from the birthing canal.
The midwife testified she approached freeing the baby as she would a vaginal examination, by splaying her index and middle fingers to try and break the suction but did not recall pushing on the skull.
Tragically, the manoeuvre caused significant head injuries to Nixon, including skull fractures and brain swelling.
In delivering his findings on Wednesday, Deputy Coroner John Lock found neither the midwife nor any other staff member at the hospital was directly responsible for Nixon’s death.
Mr Lock said the midwife should never have been placed in that situation and the root cause of Nixon’s death was the overall delay in his delivery that allowed his head to become stuck.
He also found hospital staff were not responsible for the death of Archer Langley, who died shortly after a caesarean at the same hospital just eight weeks after Nixon.
The court heard Archer died from amniotic fluid aspiration, a very rare event that prevents a baby from clearing its lungs.
Mr Lock found while there were delays in identifying Archer’s obstructed labour and proceeding to a caesarean, there were no clear links between those delays and the cause of death.
In a statement released on behalf of Nixon and Archer’s families, lawyer Sarah Atkinson said it was shocking the newborns’ deaths happened within just weeks of each other.
“It is clear there was a poor culture in the obstetric unit, with the coroner identifying poor communication, a lack of consulting input and a fear by more junior staff of escalating concerns.”
Ms Atkinson said it was inconceivable lessons were not learned from the death of baby Mia Davies, who died at the same hospital in April 2010.
A coronial inquest in 2012 found Mia died as the result of oxygen deprivation during the inadequate management of her mother’s labour.
Mr Lock noted the hospital had made significant changes over recent years to prevent similar deaths and recommended increased awareness of those changes and additional staff training.
Clinical director of obstetrics and gynaecology Karin Lust said the hospital would actively consider the recommendations with a view to implementing them as soon as possible.
“While infant mortality is rare and rates are very low in Australia, no birth is without risk,” Prof Lust said.
“Our job is to minimise possible complications to ensure a healthy mum and baby.”