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A newborn baby's death may have been prevented had his heart rate been properly monitored and his delivery hastened, a coroner has found.
Bodhi Leo Searle died in August 2021, the day after his birth at Flinders Medical Centre in Adelaide.
The cause of death was hypoxic ischaemic encephalopathy or a lack of blood and oxygen to the brain.
In her findings on Friday, South Australian Coroner Naomi Kereru said the mother's pregnancy had been largely uneventful but after being admitted to hospital and with her labour not progressing a decision was made to watch her more closely.
During this time there was a period when Bodhi's heart rate went unchecked with a monitor connected to his mother's heart instead in what coroner Kereru said was a "fundamental and tragic error".
By the time the baby was properly monitored he was found to be in foetal distress, with a trace showing a severely abnormal heart rate for a period of about 13 minutes.
A decision was made to deliver Bodhi urgently but the doctor on site was not sufficiently experienced to conduct the complicated instrument procedure.
An on-call consultant was contacted but by the time she arrived at the hospital the boy's mother had begun to effectively push and he was delivered a few minutes later.
Resuscitation efforts were performed, but were not enough to reverse the damage that had been done, the coroner found.
"It is difficult to know at what point exactly the hypoxia from which Bodhi succumbed was irreversible," Kereru said.
"However, it is important to acknowledge that delivering him at any time earlier than he was may have prevented his death."
The coroner said expert evidence to the inquest suggested there were signs of foetal distress as early as 90 minutes before the birth and that there were a number of missed opportunities during the course of the labour to recognise those issues and adequately respond.
The coroner said following the boy's death, a number of practical and sensible changes had been made at the hospital to provide a safety net for when errors occurred, including a check system to ensure heart rate monitors were correctly connected and a nurse allocated to watch it at all times.
But she said the hospital's current procedures did not require a consultant to be on-site overnight, with the onus on a more junior doctor to notify the senior clinician if they wanted them there.
Kereru said that was an unrealistic expectation and placed an uncomfortable onus on the less-experienced doctor.
The coroner recommended all SA maternity hospitals consider a policy that ensured the most senior registrar on duty was appropriately credentialled to perform complex deliveries independently, unless there was a consultant on-site and available.
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