Baby Bodhi Leo Searle dies at Flinders Medical Centre after mother’s heart rate mistakenly monitored, court told

A baby has died at a major Adelaide hospital after a mistake over a heart-rate monitor went unnoticed for nearly half an hour, a court heard. Warning: Distressing content

A one-day old infant died in hospital after his mother’s heart rate was mistakenly monitored for 26 minutes during the birth instead of his “severely abnormal” heart rate, a court has heard – prompting a public apology at an inquest into the boy’s death.

Coroner Naomi Kereru is investigating the circumstances surrounding the death of baby Bodhi Leo Searle, who died on August 31, 2021, a day after he was delivered at Flinders Medical Centre.

Opening the inquest, counsel assisting the coroner, Sally Giles, said an expert would give evidence Bodhi was likely to have been healthy at the start of labour and that his death was “potentially preventable” had his heart rate been correctly monitored.

She said Bodhi’s mother Diana Searle had an uncomplicated, normal pregnancy and went into labour on August 29, 2021 – her 30th birthday – and attended the hospital about 5.30pm after her usual midwife informed her she was ill.

The inquest heard another midwife, Stephanie Geyer, had gone home but was asked to return to the hospital to care for Mrs Searle, along with first-year student midwife Thea Koke.

Ms Giles said Ms Geyer first noticed something was amiss with the baby’s heart rate at 11.26pm. Mrs Searle was then moved to the medical ward for CTG monitoring, which began 18 minutes later at 11.44pm.

“However, at approximately 12.15am, it was identified that for around 30 minutes the CTG trace had been recording the maternal heart rate and not the foetal,” she said.

“Corrections were made to identify the foetal heart rate, which by that time was severely abnormal.”

The inquest heard the registrar and only obstetrician on the ward that evening was called, but was “not feeling confident” to perform what she expected to be a “complex instrumental delivery on her own”. She contacted the on-call consultant but Bodhi was delivered without the need for instrumental intervention just before 1am.

He was clinically blue and pale.

“It was immediately apparent that something was wrong. Bodhi’s Apgar scores at birth were zero,” Ms Giles said.

“There was no evidence of any respiratory effort and there was no identifiable heart rate or pulse present.”

Student midwife Thea Koke outside the Coroner’s Court. Picture: NCA NewsWire

Resuscitation began immediately but it was 18 minutes before his first gasp of air. He was taken to the neonatal intensive care unit where monitoring showed abnormal brain activity.

Bodhi passed away peacefully at 1.18pm on August 31, 2021.

At autopsy his cause of death was hypoxic ischaemic encephalopathy.

Ms Giles said expert witness Associate Professor Stefan Kane would tell the inquest the almost 1.5-hour delay from first noticing something was amiss with Bodhi’s heart rate to birth was “clinically inappropriate” and that “earlier intervention” could have resulted in “a more favourable outcome”.

She said he had concluded Bodhi’s death was “potentially preventable”.

“It was probable that earlier application of the CTG and earlier confirmation of foetal rather than maternal heart rate tracing would have permitted earlier identification of foetal compromise which in turn would have prompted earlier efforts to expedite the birth,” Ms Giles said.

“According to Professor Kane, Bodhi was not a baby who would have been expected not to survive labour and had the opportunities been taken to identify and act on foetal compromise earlier, Bodhi’s death would have been much more unlikely.”

She said the inquest would explore issues including why it took 26 minutes to identify it was the wrong heart rate being monitored, what could or should have been done for an earlier delivery and if whether Bodhi’s death would have been prevented if he was delivered earlier.

In a statement delivered at the start of the inquest, Lauren Gavranich, for the Southern Adelaide Local Health Network – which includes FMC – apologised for the “tragic circumstances surrounding” Bodhi’s death.

“ (SALHN) acknowledges that there were missed opportunities that may have made Bodhi’s death less likely,” she said.

“It is SALHN’s position that these opportunities were missed as a result of a number of systems issues in place at the time.

“SALHN wishes to apologise to the family for what happened to Bodhi and for what the family has experienced.”

The inquest’s first witness, student midwife Thea Koke – who was in her first year of study at the time – told the court she was tasked with attaching the CTG monitor.

She said Ms Geyer had also adjusted the CTG monitor at some stage.

She said her memory was there was “no extreme urgency” in the delivery room because an episiotomy was not performed straight away.

She told the court she had helped deliver Bodhi and had placed him on to Mrs Searle’s chest before he was taken to be resuscitated.

She said “the whole room changed” after Bodhi was born.

“I think everybody saw what Bodhi looked like and straight away was concerned,” she said.

Ms Geyer is scheduled to give evidence at the inquest on Tuesday. The inquest continues.