Father rejects coroner's conclusion on newborn son's death

The grieving father of a baby who died five days after birth has rejected the findings of a Queensland coronial inquest that found the death was not preventable.

Hugo McGregor was born by emergency caesarean section at Mackay Base Hospital in March 2023 and transferred to Townsville University Hospital, where he died.

An inquest into his death was held in Townsville last year after Jenna and Andre McGregor raised concerns about their son's care before his birth.

On Wednesday Deputy State Coroner Stephanie Gallagher found 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."

Father 'deeply disappointed'

In 2025 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.

In a statement provided to the ABC on Friday, Mr McGregor said he would apply to the state coroner to have this week's set aside, saying there needed to be "greater transparency and safer maternity care in Queensland".

He said an earlier hospital and health service internal review found shortcomings in the care provided.

"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's statement said.

"As his father, I am entitled to ask why so many of those failures appear to have had so little impact on the ultimate findings."

Mr McGregor said he was disappointed that his wife was not called as a witness.

In her findings, Magistrate Gallagher accepted that the hospital had made changes since Hugo's birth and was satisfied they were appropriate.

These included embedding obstetric ward rounds to allow for earlier patient review by the obstetrics team and improvements to staff culture.

Magistrate Gallagher said expert witnesses had not raised these issues as relevant to Hugo's death.

"There are no further recommendations this Court could make with respect to the maternity services at MBH or the management of labour pursuant to the relevant policies and guidelines more broadly," her findings said.

Cause of death

Ms Gallager listed the cause of Hugo's death as hypoxic-ischaemic encephalopathy caused by a sudden and profound onset of bradycardia (slow heart rate).

The inquest heard 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 Hugo developed metabolic acidosis — an accumulation of carbon dioxide and lack of oxygen — that caused a sudden "crash" in his 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, the inquest heard.

"These factors made it more likely that, once Hugo's capacity for physiological buffering was exhausted, he would develop a sudden bradycardia," the inquest findings said.

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".

Uncomplicated pregnancy

The Inquest into newborn's hospital death heard 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.

By 3pm she was given an infusion to strengthen labour contractions. This was stopped at 4:01pm, when Hugo's heart experienced a "sudden and profound drop" and she was taken to the operating theatre.

The inquest heard one midwife recall that staff could not find a heartbeat as they neared the operating theatre, a distance of 800-900 metres from the labour ward.

"By the time Jenna reached the operating theatre Hugo had been bradycardic for about 18 minutes," Magistrate Gallagher wrote.

The inquest heard there was a disagreement when a decision was made to try a spinal anaesthetic instead of a general anaesthetic as recommended by the midwives.

"None of the witnesses could recall precisely the time that elapsed between the failed attempt at a spinal anaesthetic and the administration of a general anaesthetic," the findings said.

"It was likely no more than a matter of minutes. The disagreement between the RMs (registered midwives) involved and the anaesthetic team was unfortunate and ideally should have been avoided.

"Any delay caused by the failed attempt, was unlikely however, to have had any material impact on Hugo's condition when born, or on his prognosis."