A BABY’S death could have been prevented if staff at Sunshine Hospital had monitored her more closely.
Coroner Kim Parkinson said failure to increase foetal monitoring had contributed to the death of Dishita Madamshetty.
In her findings handed down this afternoon, Ms Parkinson said Dishita had been conceived through in-vitro fertilisation treatment in India.
Her parents, Shashi and Vasu, had been trying to conceive for eight years.
They then returned to Australia for the baby’s antenatal and obstetric care.
On August 23, 2007, Mrs Madamshetty was three days overdue when she went to Sunshine Hospital with period-like pains, vaginal bleeding and complaining of a headache but was discharged and told to go home.
She had wanted a caesarean section because of her concerns about the high risk nature of her pregnancy.
The coroner said Mrs Madamshetty returned to the hospital on August 27 for a scheduled antenatal appointment and complained of an upper respiratory infection.
She was advised to obtain some cough medicine from her chemist and see her GP if there was no improvement.
Mrs Madamshetty was back at the hospital three days later and gave birth to Dishita by caesarean section at 10.26am.
The baby was born in poor condition and later transferred to the Royal Children’s Hospital where she died on September 30 of hypoxic brain injury.
Ms Parkinson said evidence was given by specialist obstetrician and gynaecologist, Dr Christine Tippet, who said a plan should have been made to expedite delivery of the baby when the mother presented with pain and bleeding on August 23, “particularly in light of the fact that she had conceived with the aid of IVF after prolonged infertility”.
“I do not consider discharging a mother with Panadeine Forte in this clinical situation was appropriate,” Dr Tippet told the inquest on Dishita.
“There is no doubt that this baby was most unwell from the time the mother presented (at hospital) and it is probable that expediting delivery would have resulted in the delivery of an infant in significantly better condition.”
The coroner said she was satisfied that it was likely, had intervention occurred on August 27 to increase foetal monitoring, that the baby’s deteriorating condition would have been identified and steps taken to intervene to deliver the baby, and death would have likely been prevented.
Ms Parkinson said the family claimed there was a deficiency in the passing on of clinical information to those responsible for Mrs Madamshetty’s care.
In particular, there was no information available to the midwife performing the cardiotocograph (CTG) monitoring of the baby’s foetal heart rate as to how Mrs Madamshetty had been bleeding and was in pain on August 23.
The coroner agreed with the family’s submission that it would be helpful for all of the midwifery and obstetric clinicians caring for the patient to have an overall picture available to them.
She recommended that Sunshine Hospital adopt and publish formal procedures in relation to CTG monitoring and supervision, including regular monitoring of foetal heart rates.
The Madamshettys are suing the hospital for medical negligence in the County Court.
