A baby has died after being "inadequately treated" in hospital for serious injuries sustained during a prolonged and complicated labour, a coroner has found.
ACT Coroner's Court findings published on Friday detail a series of errors made by Canberra Hospital staff, contributing to the baby's tragic death two days after being born.
Those failures included misdiagnosing the position of the baby's head, an unreasonable delay in performing a caesarean section, the misplacement of a vacuum cup during labour, and a delay in recognising, and the mistreatment of, an injury.
Canberra Health Services, on behalf of the territory government, has acknowledged aspects of the treatment and care received by the child were inadequate.
"Baby X", as he is named in the coronial inquest findings, died on October 14, 2017, from scalp and brain injuries. The baby's death would not be referred to the ACT chief coroner for almost two years.
Doctors unsuccessfully tried delivering the child with a vacuum cup, the use of which was found to be the major cause of his scalp injury, being a massive subgaleal haemorrhage. They then tried forceps.
But after it became clear the baby's head was severely impacted, one doctor determined a caesarean section was required.
Based on medical records, an expert witness said it took about 18 minutes to deliver the baby's head and it was highly likely he was "deprived of oxygen for a period during this process".
The professor of obstetrics and gynaecology submitted there had been an unreasonable delay in performing the caesarean section and the initial incision used was inadequate.
Another expert witness said the vacuum cup was not applied properly due to the baby's positioning, which two doctors reportedly disagreed on but could have been determined by an ultrasound.
That expert also found the emergency caesarean was performed too late.
The delivered baby was taken to the hospital's Neonatal Intensive Care Unit, where his scalp injury was only detected by a senior staff neonatal paediatrician when the child went into cardiac arrest.
The coronial inquest was told had that paediatrician been present at the birth, the injury would likely have been detected and treated sooner.
But the injury, a third expert said, was also mistreated.
"I am unable to say whether the earlier identification and treatment of the subgaleal haemorrhage would have saved Baby X's life," coroner Ken Archer said in his factual findings.
"The failure to provide him with adequate care after his birth deprived him of a chance of survival."
Since the baby's death, Canberra Health Services have mandated the use of ultrasound where there "is a discrepancy or uncertainty regarding the position of a foetus".
In October 2017, the hospital's procedure guidelines did not include a requirement to perform scalp observations on babies who had experienced an instrument-based delivery.
Since then, a comprehensive guideline applied to all newborns has been implemented. It mandates hourly observation for four hours after birth.
Mr Archer delivered his findings on Wednesday after not holding a hearing, which he described as being unnecessary for a number of reasons that included most of the evidence in the case being not in contest.
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