Inquest Into The Death Of Baby X

0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associated with asphyxia and mechanical factors during prolonged obstructed labour and inadequate post-natal care

Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged asphyxia during difficult delivery, and massive subgaleal haemorrhage from unsuccessful vacuum extraction. Clinical failures included: inadequate determination of fetal position (no ultrasound used despite disagreement between clinicians), incorrect placement of vacuum cup, unreasonably delayed caesarean section, and critically, delayed recognition of subgaleal haemorrhage in NICU. The haemorrhage went undetected until cardiac arrest at 15+ hours post-birth, despite visible scalp bruising from 27 minutes after birth. Delayed recognition deprived Baby X of timely blood product transfusions and contraindicated cooling therapy was inappropriately continued. CHS has since implemented scalp examination protocols and ultrasound guidance policies.