Coroner releases findings after Gladstone baby death inquest
"WHILE the past cannot be changed, lessons learned can be beneficial in preventing a repeat of these tragic circumstances."
With these words coroner David O'Connell yesterday handed down his findings from the inquest into the death of Millah Keldie-Roulston, just hours after her birth at Gladstone Hospital.
Millah died at 4.55am on February 11, 2016, despite staff at the hospital having worked frantically to resuscitate her after she was born the previous night struggling to breathe.
Late the previous evening, she was also dropped on her head by a midwife hurrying between birthing suites to reach a functioning resuscitator, after one was found to be inoperable due to a missing piece.
Tasked with determining an official cause of death, Magistrate O'Connell said the medical issues in the case were complex and some differences of opinion among those who had testified at the inquest had required resolution by him.
He found Millah had died due to three primary causes: intracranial and intrapulmonary haemorrhage, a traumatic head injury from the fall, and a Group B Streptococcus infection she had been born with.
Mr O'Connell said the fall had been "a tragic and most unfortunate event but entirely accidental".
He officially recommended a bassinet and trolley always be available in birthing suites and that babies only be taken from room-to-room using that bassinet and trolley - but noted those recommendations had already been implemented at Gladstone Hospital.
Mr O'Connell also found that antibiotics prescribed for Millah by a doctor to treat infection had not been administered. And though he accepted staff had been working to resuscitate and stabilise Millah as their first priority, he said the administration of those antibiotics "certainly (seemed) possible" when an IV canula was established at 12.20am.
He also found the pre-natal care "was not appropriate in all the circumstances" and there were "significant missed opportunities", including having pregnancy induced earlier, which could have lowered the risk of infection.
Mr O'Connell said he made "no criticism of the resuscitative efforts made" by hospital staff, given Gladstone Hospital is a level 3 tertiary hospital.
But he said the care received during the first four minutes of Millah's life was deficient given the lack of ventilation support, calling it a "glaring omission".
Crucially, Mr O'Connell said staffing arrangements did not appear to have contributed to Millah's death and did not refer any of the staff involved for investigation.
Central Queensland Hospital and Health Service chief executive Steve Williamson said CQHHS welcomed the Coroner's findings, and his thoughts and deepest sympathies went out to Millah's parents.
CQHHS acting executive director of nursing and midwifery Sue Foyle said CQ Health was working with Millah's mother Brieaan Keldie to develop a patient information brochure outlining the risks of Group B Streptococcal.