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Healthcare | Legal

Perinatal mortality cases – what can we do better?

28 May 2018, by Amy Sarcevic


In June 2014 baby Nixon Tonkin died shortly after birth at the Royal Brisbane and Women’s Hospital.

Following an induction of labour and approximately two hours of active pushing, obstructed labour was diagnosed and a decision was made to conduct a caesarean section – during which the obstetric registrar encountered significant difficulty in disimpacting the baby’s head from the mother’s pelvis.

A midwife was asked to assist with disimpaction by pushing up on the baby’s head vaginally. At birth baby Nixon was not breathing and, despite resuscitation efforts, showed no signs of recovery and was declared deceased shortly after his birth.

An autopsy found baby Nixon’s death was due to significant skull fractures, which most likely occurred when the midwife’s fingers were pushing on his head during attempts to disimpact his head from the pelvis. The midwife had no prior training or experience in such a procedure.

Two months later a second infant, baby Archer Langley, died at the same hospital also very shortly after his birth, prompting the commencement of two separate inquests.

The inquests concluded that no single staff member was accountable for the deaths – rather there was a chain of unfortunate circumstances, including (in the case of baby Nixon) delay in the availability of senior medical staff to assist in his delivery at a crucial time.

Whilst the inquests allowed the families to hear from those clinicians involved in their labour and delivery of their infant sons, and resulted in potential learnings for clinical and executive staff, concerns were raised about the impact of the coronial process on all involved.

The inquests, which heard a combined 28 witness accounts and involved ten days of hearings, were labelled ‘traumatic’ by some of those required to give evidence.

Further, lawyers for some of the clinicians argued successfully for an order prohibiting publication of information that would identify those individuals, following sensationalised media reporting of certain evidence in the first days of the inquest, raising concerns about individual wellbeing and reputational damage.

In light of cases such as these, the Obstetric Malpractice Conference will hear from Deputy State Coroner John Lock who led the inquests and handed down the final verdict.

Mr. Lock will reflect candidly on both cases, as well as several others, offering specific recommendations on what can be better next time round.

In advance of his presentation at the conference, Mr. Lock said, “It is appropriate that we take the time to reflect on these cases and invite opinions on how the processes surrounding them can be improved.”

“I am very cognisant of the distress that can result from inquest proceedings which, whilst intended to be non-adversarial and in some ways therapeutic, can also have unintended counter-therapeutic impacts not just on families but also on those who appear as witnesses. I commend conferences such as this for addressing this important but often overlooked aspect of the coronial jurisdiction”.

Learn more about the Obstetric Malpractice Conference and book your place here.

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