Changes made by Albury Wodonga Health after death of eight-day-old boy

The child was born by an emergency cesarean at Wodonga hospital on December 6, 2019.

The boy's mother had attended hospital multiple times during her pregnancy amid concerns about reduced movements.

Several ultrasounds failed to find any abnormalities, but a check five days before birth showed a high amniotic fluid reading.

Issues were found on December 6, leading to the emergency birth.

The newborn experienced a range of medical issues after his birth and was taken to the intensive care unit at the Royal Children's Hospital in Melbourne.

Further tests showed an extensive brain injury and the boy died on December 14 after his life support was withdrawn.

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The boy's mother raised several concerns with the Victorian coroner, including that she had instructed obstetricians and doctors to make enquiries into blood flow of the umbilical cord and was repeatedly told there were no issues.

She said she had also been told everything was normal despite concerns about a lack of movement during the final stages of pregnancy.

Coroner Katherine Lorenz investigated the matter.

She did not make adverse findings against Albury Wodonga Health, but noted the importance of health staff ensuring the accuracy of all medical documentation and information sharing, and the importance of placental pathology in the instance of perinatal deaths.

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Midwifery and nursing director Julia Wright said changes had been made.

"Ms Wright reported that AWH has since strengthened and updated its practice of information sharing to include adding printouts from the hospital notes from the birthing outcomes system for all women attending the hospital during pregnancy for appointments to the maternity outpatient clinic," the coroner noted.

"This includes ensuring ultrasound results, notes and management plans are attached to the woman's hand-held Pregnancy Health Record - a patient record carried by the woman throughout the pregnancy that the women can provide to each pregnancy care practitioner she attends."

Changes concerning placental histopathology have also been made.

"I convey my sincere condolences to (the boy's) family for their loss and acknowledge the profound grief and sadness brought to them following his unexpected passing," Ms Lorenz said.

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