A fatal brain injury suffered by a baby boy in Tasmania occurred during a "mismanaged" hospital birth involving "poor clinical decision-making" that did not follow relevant guidelines.
The boy, known as KN, was delivered at the Launceston General Hospital in October 2019 in a traumatic labour that resulted in a severe hypoxic brain injury, caused by lack of oxygen.
He died two weeks later after being placed in palliative care.
The boy's mother was admitted to the hospital for an emergency caesarean section, a procedure she was "keen" to have, after a routine examination found he was in a legs-first breech position.
Obstetricians tried various manoeuvres over about 40 minutes but were unable to deliver the boy.
An emergency caesarean section was then undertaken to try to free his arms and head.
He was was born vaginally in a "critically unwell" condition shortly afterwards.
In a coronal report published on Wednesday, an obstetrics and gynaecology specialist determined a "clear clinical assessment of suitability for attempting vaginally breech birth was not conducted".
Dr Jonathan Nettle said at any time in the 26 minutes after the mother's membranes ruptured it would have been possible to perform a comparatively straightforward caesarean section.
He said the birth was a "difficult clinical situation that appears to have been made worse by poor clinical decision making which did not adhere to standard relevant guidelines".
"There were multiple opportunities presented to staff present to take an alternative course of action that would have likely avoided the final outcome," he said.
Coroner Simon Cooper ruled the Launceston General Hospital "mismanaged" the boy's birth.
He said subsequent care was appropriate but "by then, the hypoxic brain injury he had suffered during birth meant he had no hope of survival".
Mr Cooper said draft findings were sent to the hospital for comment.
An email reply from the hospital's executive director of medical services expressed "personal criticism" of Dr Nettle's experience.
Mr Cooper said the hospital's medical director of women's and children's services indicated the facility is investing in a simple ultrasound unit to confirm foetal presentation.
