Coronial
ACThospital

Inquest Into The Death Of Baby X

Deceased

Baby X

Demographics

0y, male

Coroner

Coroner Archer

Date of death

2017-10-14

Finding date

2024-09-11

Cause of death

Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associated with asphyxia and mechanical factors during prolonged obstructed labour and inadequate post-natal care

AI-generated summary

Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged asphyxia during difficult delivery, and massive subgaleal haemorrhage from unsuccessful vacuum extraction. Clinical failures included: inadequate determination of fetal position (no ultrasound used despite disagreement between clinicians), incorrect placement of vacuum cup, unreasonably delayed caesarean section, and critically, delayed recognition of subgaleal haemorrhage in NICU. The haemorrhage went undetected until cardiac arrest at 15+ hours post-birth, despite visible scalp bruising from 27 minutes after birth. Delayed recognition deprived Baby X of timely blood product transfusions and contraindicated cooling therapy was inappropriately continued. CHS has since implemented scalp examination protocols and ultrasound guidance policies.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsneonatologyintensive care

Error types

diagnosticcommunicationproceduralsystemdelay

Clinical conditions

hypoxic-ischemic encephalopathysubgaleal haemorrhageprolonged labourobstructed labourfetal asphyxiahypovolaemic shockdisseminated intravascular coagulationmetabolic acidosis

Procedures

vacuum extractionforceps deliverycaesarean sectionintubationresuscitationblood transfusion

Contributing factors

  • Prolonged obstructed labour with head impaction
  • Failed vacuum extraction resulting in subgaleal haemorrhage
  • Incorrect placement of vacuum cup causing further deflexion of head
  • Inadequate determination of fetal position (no ultrasound used despite clinician disagreement)
  • Delayed recognition of subgaleal haemorrhage in NICU
  • Delayed and inadequate scalp examination protocols
  • Failure to repeat blood gases to detect persistent metabolic acidosis
  • Inappropriate use of therapeutic cooling in setting of significant blood loss
  • Delayed administration of blood products and fluid transfusions
  • Unreasonably delayed caesarean section

Coroner's recommendations

  1. Implement mandatory scalp examination protocols for newborns with instrument-assisted delivery, including hourly head observations for four hours post-birth
  2. Use ultrasound to determine fetal position when there is discrepancy or uncertainty among clinicians
  3. Ensure senior neonatal staff presence at births following instrument-assisted deliveries to identify complications such as subgaleal haemorrhage
  4. Repeat blood gases in neonates with signs of metabolic acidosis to guide fluid and blood product administration
  5. Review contraindications to therapeutic cooling in neonates with significant blood loss
  6. Ensure timely escalation and senior review in NICU for signs of hypovolaemia
Full text
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Source and disclaimer

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