Bodhi Leo Searle: Baby dies day after being born as abnormal heart rate goes undetected for 26 minutes
ADELAIDE, AUSTRALIA: A newborn baby tragically died after nurses failed to detect his "abnormal" heart rate for 26 minutes. Bodhi Leo Searle died on August 31, 2021, just a day after he was born at Flinders Medical Centre in south Adelaide.
The tragic circumstances surrounding Bodhi’s death are now being investigated by an inquiry, overseen by coroner Naomi Kereru. The probe will also look into an incident where nurses monitored Bodhi's mother's heart rate instead of his. An attorney assisting the coroner, Sally Giles, told the inquest that an expert noted Bodhi's death was "potentially preventable" if his heart rate was monitored correctly, the Adelaide Advertiser reported.
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Bodhi's mother Diana, who had a healthy pregnancy, went into labor on August 29, 2021, when she was checked into the hospital at about 5.30 pm. The mother was placed under the care of midwives Stephanie Geyer and Thea Koke, a first-year student after her regular midwife notified her that she was unwell. Giles told the inquiry that Diana was rushed to the medical ward and hooked up for CTG monitoring at about 11.44 pm after Geyer observed that something was wrong with her unborn baby’s heart rate.
Bodhi's failing health was 'immediately apparent'
"However, at approximately 12.15 am, it was identified that for around 30 minutes the CTG trace had been recording the maternal heart rate and not the fetal," she said, according to DailyMail. "Corrections were made to identify the fetal heart rate, which by that time was severely abnormal." The registrar and only obstetrician on the ward said they were "not feeling confident" to perform a "complex instrumental delivery on her own." Fortunately, Diana delivered Bodhi before 1 am without instrumental intervention.
Bodhi's failing health was "immediately apparent," according to Giles, who said he was blue, weak, and had scored zero points on his Apgar score - a measure used to evaluate a baby's color, heart rate, reflexes, muscle tone, and respiration. "There was no evidence of any respiratory effort and there was no identifiable heart rate or pulse present," Giles said. Bodhi was taken to the neonatal intensive care unit where doctors saw indications of aberrant brain activity.
What caused Bodhi’s death?
Tragically, doctors’ relentless efforts failed to save the infant as he died at 1.18 pm on August 31, 2021. According to his autopsy, Bodhi died because of hypoxic-ischaemic encephalopathy, a brain injury brought on by a lack of oxygen. Giles said witness Associate Professor Stefan Kane found Bodhi's death was "potentially preventable."
"It was probable that earlier application of the CTG and earlier confirmation of fetal rather than maternal heart rate tracing would have permitted earlier identification of fetal compromise, which in turn would have prompted earlier efforts to expedite the birth," Giles said. Student midwife Thea Koke also told the inquiry that she attached the CTG monitor to Searle before Geyer adjusted it. "I think everybody saw what Bodhi looked like and straight away was concerned," she said. Koke also testified that she even had placed Bodhi on Searle's chest before resuscitation procedures started.