A newborn baby boy died after his traumatic birth at the Launceston General Hospital, which, according to the Tasmanian Coroner, was mismanaged.
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The mother of the baby arrived at the hospital for an appointment where it was found that she was in early labor and the baby was in breech position.
An emergency caesarean was planned but the Coroner's report reveals a period of time when the obstetricians attempted a vaginal delivery.
A specialist's report found there was "poor clinical decision-making", and that a "comparatively straightforward caesarean section" would have been possible in the circumstances.
Coroner Simon Cooper said that the baby's delivery was mishandled by the hospital.
Launceston General Hospital medical services executive director Peter Renshaw said a review of the case had led to an investment in handheld ultrasound devices, and scans at the end of a pregnancy now take place if the baby's position is in doubt.
"Having regard to the evidence as a whole I have reached the conclusion that the birth of KN [the baby] was mismanaged at the LGH," Coroner Cooper wrote.
"In contrast, the care and treatment he received after his birth, both at the LGH and at the RHH [Royal Hobart Hospital] was of an appropriate standard.
"However, by then, the hypoxic brain injury he had suffered during birth meant he had no hope of survival."
The baby died in 2019 two weeks after its birth from a severe brain injury.
A Royal Australian and New Zealand College of Obstetricians and Gynaecologists fellow and specialist Dr Jonathan Nettle found that there was a 26 minute period where "a comparatively straightforward caesarean section" could have been performed.
Dr Nettle wrote that the baby's birth was a "difficult clinical situation that appears to have been made worse by poor clinical decision-making which did not adhere to standard relevant guidelines".
He added that "there were multiple opportunities presented to staff present to take an alternative course of action that would have likely avoided the final outcome".
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In the report Dr Nettle wrote that a clear clinical assessment of suitability for attempting vaginally breech birth was not conducted.
Dr Renshaw said the breech was not recognised until the mother was in labor, which resulted in complications in the delivery of the baby.
"The Launceston General Hospital reviewed the case and has introduced a quick scan at the end of pregnancy where there is any doubt about the baby's presentation," Dr Renshaw said.
"The LGH has also made changes to the provision of ultrasound machines, investing in simple, portable handheld ultrasound devices to be used in various settings," he said.
"The devices connect with a tablet screen and are more straightforward for staff to use than existing ward-based ultrasound machines."
Dr Renshaw said the Health Department will consider the Coroner's report., and noted the deeply distressing nature of the case.
"The Department is committed to continuous improvement and will carefully consider the Coroner's report, noting no recommendations were made," he said.
"The Department of Health extends its sincere condolences to the family and loved ones of the infant who sadly passed away in 2019."
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