An inquest has revealed that newborn Alby Spreadborough was observed taking two breaths following a challenging caesarean section delivery. Medical experts provided insights during the coronial inquest held in Townsville, where the coroner will deliberate on her recommendations and conclusions.
Upon birth, Alby was described as “flat, pale, and lifeless,” yet a physician noted that he took two small breaths shortly after the resuscitation efforts began. Deputy State Coroner Stephanie Gallagher is tasked with determining whether Alby was stillborn after the emergency caesarean performed at Emerald Hospital in February 2023.
Over the course of a five-day inquest into Alby’s death, it was reported that healthcare professionals did not detect a heartbeat while attempting to revive him post-delivery. Rural generalist Tristan Howie testified that he observed Alby take a “gasping” breath early in the resuscitation process, followed by another breath soon after.
According to the Coroner’s Act, if the baby is determined to be stillborn, no findings can be made. On Friday, specialist neonatologist Melissa Luig commented that the breaths detected were likely indicative of life and opined that Alby succumbed due to oxygen deprivation.
Dr. Luig, who was not directly involved in the case, suggested that although no heartbeat was detected, a very slow “electrical heartbeat” might have been present at birth. “I suspect there was a weak heartbeat at the time of Alby’s birth or shortly thereafter,” she remarked, adding that it may have been too faint to be detected manually.
Dr. Howie expressed his concerns regarding Alby’s initial breath during resuscitation attempts, stating, “It was the only sign of life we observed.” He later placed a breathing mask on Alby, witnessing another faint breath, but subsequent breathing movements were absent.
In contrast, specialist obstetrician Greg Duncombe, who was not involved in the case, asserted that there were no signs of life. Midwife Jess Nabe confirmed that she did not observe any breathing, heartbeat, or pulse. Counsel assisting Geoffrey Diehm characterized Alby as “flat, pale and lifeless in appearance” at the time of delivery.
At the end of the inquest, Coroner Gallagher stated she was convinced that Alby was not stillborn.
The inquest also examined the medical documentation leading up to Alby’s delivery, questioning whether a caesarean section should have been conducted sooner. Evidence presented suggested that the scans prior to the emergency procedure did not reveal significant concerns.
On Thursday, specialist obstetrician Rachael Nugent, who was not involved with the delivery, stated that, with hindsight, the medical team may have been “falsely reassured” by the scans, which she deemed misleading. She indicated that there were consistent signs of hypoxia—insufficient oxygen in the blood—that were not acknowledged, suggesting that an earlier caesarean might have improved Alby’s chances.
It was noted that Dr. Nugent was the only expert to hold this viewpoint among those consulted.
Rebecca and Tim Spreadborough, Alby’s parents, attended the court proceedings daily. On the first day of the inquest, Ms. Spreadborough shared that she initially requested a caesarean from her midwife an hour before the emergency procedure was carried out. In a statement to the coroner, the couple expressed that their inability to understand the circumstances surrounding Alby’s death has made their grief particularly difficult. “We need to ensure that the circumstances of his death have been thoroughly scrutinized, that challenging questions have been posed, and that all reasonable explanations have been carefully considered,” Ms. Spreadborough stated.
The inquest has also raised calls for improved education regarding Bandl’s ring, a rare medical condition that Ms. Spreadborough had developed. Midwives involved in the delivery noted that they were required to replicate the same information across various Queensland Health documents during labor. It was highlighted that although this practice has since been revised to require documentation in a single location, Emerald Hospital continues to use paper-based records.
The coroner will now review the presented evidence before issuing her findings and recommendations.
