Finding helanisirianni257 08 dscmitchell
Deceased
Helani Sirianni
Demographics
female
Date of death
2008-02-10
Finding date
2010-07-22
Cause of death
Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ failure due to a large subgaleal haemorrhage probably associated with vacuum extraction delivery
AI-generated summary
Helani Sirianni, born 8 February 2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extraction procedure itself was appropriately performed. However, critical failures in clinical escalation and recognition occurred: nursing staff failed to alert the obstetrician when the CTG trace deteriorated significantly at 1:50am, delaying delivery by 1 hour 15 minutes; the paediatrician missed early clinical signs of bleeding (vasoconstriction, boggy scalp swelling) 3.5 hours after birth, delaying diagnosis by approximately 4 hours. Although subgaleal haemorrhage is a rare but recognized complication of vacuum delivery, and treatment options are limited, earlier recognition might have prolonged circulatory support. The coroner emphasized the need for improved neonatal observation policies with clear vital sign monitoring triggers, staff education in recognizing blood loss, and robust escalation procedures. The Area Health Service subsequently implemented comprehensive policy improvements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Subgaleal haemorrhage
- Hypovolaemic shock
- Disseminated intravascular coagulopathy
- Multi-organ failure
- Failure of nursing staff to escalate fetal distress concerns (CTG deterioration at 1:50am not reported to obstetrician)
- Failure to recognize early clinical signs of bleeding (vasoconstriction, boggy scalp swelling)
- Delay in diagnosis of subgaleal haemorrhage (approximately 4 hours)
Coroner's recommendations
- Amend the Observations: Neonatal policy document to eliminate any ambiguity and require blood pressure monitoring at 15 minute intervals for four hours and then hourly until stable
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