Baby C - non-inquest findings

0y · Male·meconium aspiration syndrome complicated by persistent pulmonary hypertension

Baby C was born at 41 weeks and 2 days covered in thick meconium with respiratory distress. Key clinical failures included: (1) failure to respond to mother's request for induction at term+6 days; (2) failure to investigate elevated fetal heart rate of 160 bpm at last antenatal visit; (3) failure to intubate before suctioning meconium—non-intubated laryngoscopic suctioning did not meet international standards; (4) critical delay contacting Townsville Hospital NETS until 9 hours of age when early contact (within 2 hours) would have enabled timely retrieval and nitric oxide therapy; (5) NETS arrival delayed by 5+ hours due to aircraft unavailability. Baby C deteriorated despite initial stabilisation, developing pneumothorax and pleural effusion. Nitric oxide was only attempted at 16 hours when Baby C was moribund. Experts agreed earlier retrieval by 5 hours of life would likely have prevented death. Hospital lacked level 6 capability and nitric oxide infrastructure. Contributing factors were underestimation of MAS severity, missed opportunity for maternal request honoring, and system delays.