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Inquest into death of newborn baby Bodhi Searle at Flinders Medical Centre in Adelaide

Baby dies a day after birth because nurses accidentally monitored his mother’s perfectly normal heartbeat instead of his for 26 minutes

  • Bodhi Leo Searle passed away on August 31, 2021
  • He had an abnormal heartbeat

The death of a newborn baby whose ‘abnormal’ heartbeat went undetected for 26 minutes was found to be ‘potentially preventable’.

Bodhi Leo Searle tragically passed away on August 31, 2021, just one day after being delivered to Flinders Medical Center in South Adelaide.

An inquest, overseen by coroner Naomi Kereru, is looking into the circumstances of Bodhi’s death – including an incident where his mother Diana Searle’s heartbeat was accidentally checked instead of his.

The coroner’s counsel, Sally Giles, told the inquest that it will later hear evidence from an expert witness that Bodhi’s death was “potentially preventable” if his heartbeat was properly monitored, the Adelaide advertiser reports.

Bodhi’s mother, Ms. Searle, had a normal pregnancy and gave birth on August 29, 2021 – her 30th birthday – and went to the hospital at about 5:30pm.

Bodhi Leo Searle (pictured with his parents) died a day after he was born in South Adelaide

She was placed in the care of midwife Stephanie Geyer and first-year student midwife Thea Koke after her usual midwife told Ms. Searle that she was ill.

Ms Giles told the inquiry that at 11:26 pm Ms Meyers first noticed something was wrong with Bodhi’s heartbeat.

Ms. Searle was taken to the medical unit at approximately 11:44 PM and hooked up for CTG monitoring.

“However, at about 12:15 p.m., the CTG trace was found to have recorded the maternal heart rate and not the fetal heart rate for about 30 minutes,” she said.

“Corrections were made to identify the fetal heart rate, which was seriously abnormal by then.”

The clerk and the only midwife on the ward said they “didn’t feel confident” to perform a “complex instrumental delivery” on her own.

However, Bodhi was delivered shortly before 1 a.m. without instrumental intervention.

Ms Giles said Bodhi’s ill health was ‘immediately apparent’. He was blue, pale and scored zero points on his Apgar score – a commonly used measure of a baby’s color, heart rate, reflexes, muscle tone and breathing.

‘There was no evidence of any respiratory effort and no identifiable heartbeat or pulse was present,’ said Ms Giles.

Mother Diana Searle went to Flinders Medical Center (above) on August 29, 2021, where her heart rate was accidentally checked instead of Bodhi's

Mother Diana Searle went to Flinders Medical Center (above) on August 29, 2021, where her heart rate was accidentally checked instead of Bodhi’s

It took Bodhi 18 minutes to take his first breath.

He was rushed to the neonatal intensive care unit, where doctors discovered signs of abnormal brain activity.

Bodhi Searle died on August 31, 2021 at 1:18 PM.

His autopsy revealed that he suffered from hypoxic ischemic encephalopathy – a brain injury caused by a lack of oxygen.

Ms Giles said Witness Associate Professor Stefan Kane felt Bodhi’s death was ‘potentially preventable’.

“It was likely that earlier application of the CTG and earlier confirmation of fetal rather than maternal heart rate measurements would have allowed earlier identification of a fetal defect, which in turn would have led to earlier efforts to hasten birth” said Mrs Giles.

Student midwife Thea Koke was the first witness to the inquest.

She said she attached the CTG monitor to Ms. Searle and that Ms. Geyer later adjusted the monitor.

First-year student midwife Thea Koke (pictured outside the Coroner's Court) said Bodhi's post-birth appearance was concerning

First-year student midwife Thea Koke (pictured outside the Coroner’s Court) said Bodhi’s post-birth appearance was concerning

Ms Koke said there was ‘no extreme urgency’ in the delivery room and that she placed Bodhi on Ms Searle’s chest before resuscitation efforts began.

“I think everyone saw what Bodhi looked like and immediately got concerned,” she said.

Lauren Gavranich apologized on behalf of the Southern Adelaide Local Health Network – which includes Flinders Medical Center – for the “tragic circumstances surrounding” Bodhi’s death.

The judicial investigation continues.