Baby's death not preventable, coroner finds

A coronial inquest has found that the death of a baby born at a Mackay hospital in 2023 was not preventable, despite his parents expressing concerns about his care before his birth.

Hugo McGregor was born by emergency caesarean section at Mackay Base Hospital in March 2023 and transferred to Townsville University Hospital, where he died five days later. An inquest into his death was held in Townsville last year after his parents, Jenna and Andre McGregor, raised concerns about their son's care.

Deputy State Coroner Stephanie Gallagher found that there were no missed opportunities that may have changed the outcome. "I accept that it is theoretically possible that had he been delivered earlier, he may have been born in better condition," she said in her findings.

"However, the expert evidence is clear that the care provided to both Jenna and Hugo was reasonable and appropriate, and there were no prospective reasons to warrant an earlier delivery or any additional intervention or escalation beyond what was done."

Jenna McGregor told the court that she and her husband would never forget Hugo.

The inquest heard that the McGregors felt hospital staff should have been concerned at the lack of labour progress earlier and considered an earlier caesarean, and that the delay in receiving an epidural contributed to their son's death.

"My son died following a series of events in a Queensland public hospital. A Root Cause Analysis subsequently identified dozens of failures. Yet not one of these were mentioned during the inquest," Mr McGregor said in a statement.

Mr McGregor expressed disappointment that his wife was not called as a witness and said he would apply to the state coroner to have the findings set aside, citing a need for "greater transparency and safer maternity care in Queensland".

The inquest heard that Hugo was born "pale, floppy and unresponsive" and after being resuscitated was transferred to Townsville University Hospital, where he died five days later. An obstetrics expert, Edward Weaver, told the inquest that Hugo developed metabolic acidosis — an accumulation of carbon dioxide and lack of oxygen — that caused a sudden "crash" in his heart rate.

The cause of death was listed as hypoxic-ischaemic encephalopathy caused by a sudden and profound onset of bradycardia (slow heart rate). An autopsy showed the placenta had signs of infection and inflammation, which likely impaired its function and increased metabolic demands on the baby.

Magistrate Gallagher wrote in her findings that a family statement was read at the conclusion of the evidence, "which made clear that Hugo was loved and cherished by his parents from the moment of his conception, and by his grandparents and extended who had long hoped to meet him".

The inquest heard that Ms McGregor had an uncomplicated pregnancy and was transferred from Proserpine to Mackay because there were no anaesthetists on-call due to fatigue. She arrived in Mackay at 6am on March 11, 2023, and by 9:10am had requested an epidural, which was not administered until two hours later, when an anaesthetist was available.