NEVER AGAIN: Inquest into Gladstone baby's death concludes
THE coronial inquest into the death of a newborn baby at Gladstone Hospital concluded yesterday, bringing an emotional end to a three-day ordeal for the family of Millah Keldie-Roulston.
Counsel assisting the coroner John Aberdeen made no submission as to whether legal or disciplinary action should be taken against hospital staff present when Millah died - but he believed the evidence heard at the inquest supported neither action being taken.
Over three days of witnesses, the inquest was told how Millah's mother Brieaan Keldie was driven to Gladstone Hospital by her partner Adam Roulston late at night on February 10, 2016, after experiencing painful and increasingly severe contractions.
She gave birth to Millah standing up in one of the birthing suites, and the midwives attending immediately noticed the newborn baby was not moving or breathing properly.
When one of the midwives carried the baby to the suite's resuscitaire, she noticed the machine was missing an adapter needed to operate properly - and as she hurried to carry the baby to a machine in another suite, she slipped and fell on a patch of wet floor, dropping Millah to the ground.
It likely took between two and three minutes before resuscitation efforts began.
Millah died at 4.55am on February 11, after continuous efforts by the midwives and two doctors to revive her.
She was later found to have a fractured skull and a severe Group B streptococcal (GBS) infection, for which she never received antibiotics.
Mr Aberdeen yesterday submitted coroner David O'Connell should record Millah's primary cause of death as the GBS infection, with injuries sustained by the fall recorded as a contributing cause.
He submitted midwife Gabrielle Matamoros's decision to take Millah to the next birthing suite to use another resuscitaire, rather than use a nearby Ambu bag resuscitation device, was reasonable.
But he also said Mr O'Connell should find that prior to the birth, Ms Keldie did not have enough information about the risk posed by GBS, the equipment at the hospital was not adequate or operable at the time, and antibiotics should have been administered shortly after 12.20am when IV access was established.
Mr Aberdeen submitted Mr O'Connell make a formal recommendation that hospitals no longer mix and match components from different manufacturers, meaning easily-lost adapters such as the one missing from the resuscitaire would not be needed.
He said it could even be said manufacturers had a moral obligation to ensure their lifesaving machines were compatible, as in the case it was a General Electric resuscitaire and a Fisher & Paykel set of tubing that would not connect without the adapter manufactured by a third party.
He submitted Mr O'Connell should also recommend movable cots be available in all birthing suites, to prevent midwives having to carry babies in emergency situations.
The inquest earlier heard evidence that both of those steps have already been taken by Gladstone Hospital, along with the installation of non-slip floors around the maternity ward.
The inquest also heard evidence from Rockhampton-based CQHHS director of nursing and midwifery Susan Foyle that since Millah's death, Gladstone Hospital has established a "code blue" policy which outlines the need to get more help quickly in emergency situations.
Ms Foyle also testified CQHHS had volunteered to assist in developing a new approach to treating infections in children, and she would endorse expanding that effort to include children under 28 days of age.
Finally, Mr Aberdeen said Mr O'Connell should recommend all mothers in Queensland be given the choice to undergo GBS screening late in their pregnancy, with the possibility of universal screening, rather than the current policy of only at-risk mothers being screened.
The inquest was told the Central Queensland Hospital and Health Service wrote to the relevant committee in charge of the policy after Millah's death and requested the risk-based approach be reviewed and brought in to line with other states.
That committee met on June 15, 2016 and concluded there was insufficient evidence to change the policy.
"One of the reasons the guideline panel declined to change the guideline was there was no evidence it was desirable," Mr Aberdeen said.
"Obviously this one death is not evidence that renders it desirable, so the question follows: Would two deaths be enough?"
Counsel representing Ms Keldie and Adam Roulston, Holly Blattman, told the inquest the lack of antibiotics administered to Millah meant she had been "robbed of a chance to live" - though it was not possible to accurately quantify what that chance would have been.
She broadly approved of the submissions made by My Aberdeen, but also submitted the coroner should find that Ms Keldie's pregnancy should have been considered intermediate risk rather than low risk.
She said an earlier induction of pregnancy would have meant the GBS infection might have been either non-existent or more manageable by the time Millah was born.
Ms Keldie had presented at Gladstone Hospital the day prior to the night's events for a check, and been told she could return to her home at Boyne Island as she was not yet technically in labour.
Representing Gladstone Hospital, barrister David Schneidewin suggested Mr O'Connell recommend a guideline for treating infection in newborns be established as a separate protocol, rather than being integrated into the resuscitation protocol at the centre of much of the inquest's proceedings.
He suggested that, if that were to occur, Queensland Health would be open to working with Millah's family to name the new policy after her - something along the lines of "Millah's pathway".
Millah's family said they wanted to thank the Queensland Coroners Court for its efforts during the inquest.
"We hope and expect all recommendations are implemented, as it's in the safety and best interests of the public, and that all lessons are learnt from this," they said.
Coroner David O'Connell told the inquest the evidence and submissions were like a "giant medical jigsaw puzzle" that he would have to piece together before issuing findings.
He reserved his decision and is expected to release findings and recommendations within the next few weeks.