Coroner's Finding: Searle, Bodhi Leo

0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia

Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did not progress normally, the mother was transferred to a monitoring suite for continuous cardiotocography (CTG). Critically, the CTG recorded the mother's heart rate instead of the baby's for approximately 26 minutes, during which time the baby was likely experiencing severe distress. This monitoring failure occurred because the midwife failed to verify the CTG was tracing the correct heart rate, failed to prioritize monitoring despite earlier concerns about foetal decelerations, and failed to communicate concerns to senior staff. By the time a junior registrar (Dr Lindner) recognised the severely abnormal foetal heart rate, the baby had suffered irreversible hypoxic brain injury. The coroner found the death was preventable if foetal heart rate abnormalities had been recognised and delivery expedited earlier, likely between 11:56 PM and 12:06 AM. Key clinical lessons: (1) CTG monitoring must be verified as correct and actively monitored; (2) junior registrars should not be the most senior doctor on labour wards without adequate experience in complex deliveries; (3) communication failures between midwives prevented escalation of concern.