Nixon Tonkin died in June 2014 at Royal Brisbane and Women’s Hospital. Picture: AAP/Supplied by Tonkin family
Nixon Tonkin died in June 2014 at Royal Brisbane and Women’s Hospital. Picture: AAP/Supplied by Tonkin family

Coroner rules on baby Nixon's death

A CORONER has slammed the Royal Brisbane Women's Hospital, saying it could have done more in the lead up to the death of two infants in 2014.

Nixon Tonkin and Archer Langley died eight weeks apart after two complicated births on June 6 and July 25.

Coroner John Lock earlier found no individual staff member was responsible for the death of Nixon, who suffered fatal head injuries during an emergency caesarean at Queensland's largest hospital, a coroner has found.

Nixon never breathed on his own after being delivered at Royal Brisbane and Women's Hospital in June 2014.

An inquest into his death heard a midwife was asked to carry out a procedure she was not trained to do in a bid to free Nixon's head from the birthing canal.

The midwife testified she approached freeing the baby as she would a vaginal examination: by splaying her index and middle fingers to try and break the suction but did not recall pushing on the skull.

The manoeuvre caused significant head injuries to Nixon including skull fractures and brain swelling.

Mr Lock has found neither the midwife, nor any other staff member at the hospital, was directly responsible for Nixon's death.

Mr Lock said the midwife should never have been placed in that situation and the root cause of Nixon's death was the overall delay in his delivery.

He did not make any recommendations in the case, stating the hospital had already introduced significant reforms to prevent similar deaths.

In a statement, Royal Brisbane and Women's Hospital clinical director of obstetrics and gynaecology Karin Lust offered the hospital's sincere condolences to Nixon's family for their loss.

"While infant mortality is rare and rates are very low in Australia, no birth is without risk," Prof Lust said.

"Our job is to minimise possible complications to ensure a health mum and baby."

A coronial inquest heard earlier this year the newborns' mothers should've received advice regarding cesarean sections much earlier.

Mr Lock handed down his findings this afternoon and ruled more should have been done to aid the women.

"One would have real concern about the level of communication between these doctors," he said.

In a statement, RBWH's Professor Karin Lust said: "In rare and unusual events such as these, it's important that we look at what could have been done differently.

"In fact, since 2014, we have overhauled our maternity services under the guidance of an expert Obstetrics and Gynaecology taskforce."

The changes at RBWH included hiring more consultants to assist in similar situations.

Consultants are now present on every shift.

Mr Lock said at the time of Nixon and Archer's deaths there was little to no contact with consultants.

"The women and new born services is run more consultant-driven," he said.