Newborn baby Alby Spreadborough was "flat, pale and lifeless" when he was born, but an inquest has heard a doctor saw him take two small breaths.
Among the considerations for Deputy State Coroner Stephanie Gallagher is whether Alby was stillborn after an emergency caesarean section at Emerald Hospital in February 2023.
During this week's five-day coronial inquest into his death, the court heard doctors and midwives did not find a heartbeat while attempting to resuscitate Alby after a difficult delivery.
Rural generalist Tristan Howie said he saw the baby take a "gaspy" breath early in the resuscitation and another a short time later.
Under the Coroner's Act, there can be no findings if the baby is found to have been stillborn.
On Friday, specialist neonatologist Melissa Luig told the court the breaths were likely signs of life and that she believed the baby died from a lack of oxygen.
Dr Luig, who was not involved in the case, said although clinicians were unable to find a heartbeat, it was possible there could have been an undetected slow "electrical heartbeat".
"I think there probably was a very slow heartbeat when Alby was born or soon after," Dr Luig said.
"It may not have been strong enough to be palpated [felt by hand]."
Dr Howie said it was a "great concern" to see Alby take what looked like a breath during resuscitation attempts.
"It was the one and only sign of life that we saw," he said.
Dr Howie said he later put a breathing mask over Alby and saw him take another small breath, but it was not followed by any breathing movement.
"There was one effort at a breath … it was small," he said.
But specialist obstetrician Greg Duncombe, who was not involved in the case, said he believed there were no signs of life.
Midwife Jess Nabe said she did not see any breathing, heartbeat or pulse.
Counsel assisting Geoffrey Diehm said the evidence during the inquest described Alby as "flat, pale and lifeless in appearance" when he was delivered.
At the conclusion of the inquest, Ms Gallagher said she was persuaded Alby was not a stillbirth.
False signs of reassurance
The inquest also investigated issues around medical charts in the lead-up to Alby's delivery and whether a caesarean should have been performed earlier.
The court heard doctors did not find any significant concerns from scans in the lead-up to the emergency caesarean section.
However, on Thursday specialist obstetrician Rachael Nugent, who was not involved with the birth, said in hindsight, she believed doctors had been "falsely reassured" by scans, which she said were inaccurate.
Dr Nugent said "consistent signs of hypoxia" — when the baby cannot get enough oxygen into the blood — were not recognised.
If a caesarean had been performed an hour earlier, the baby may have "coped better", she said.
However, the court heard Dr Nugent was the only expert consulted who held these views.
Parents Rebecca and Tim Spreadborough have attended the court each day.
On the first day of the inquest, Ms Spreadborough said she made an initial request to her midwife for a caesarean an hour before the emergency procedure was performed.
In a statement to the coroner, the parents said not understanding why Alby died had made their grief hard to process.
"We need to know the circumstance surrounding his death have been thoroughly examined, that difficult questions have been asked and that all reasonable explanations have been properly considered," Ms Spreadborough said.
The proceedings have also heard calls for greater education about Bandl's ring, a rare medical condition that Ms Spreadborough had developed.
Midwives who were involved in the delivery told the court they were required to write identical information across multiple Queensland Health documents during the labour.
The court heard while this practice had since been changed requiring information to be noted in one location, Emerald Hospital remained paper based.
The coroner will retire to consider the evidence before publishing findings and recommendations.
