Ty lacey findings dsc guy
Deceased
Ty Lacey
Demographics
male
Date of death
2010-02-15
Finding date
2012-12-11
Cause of death
Extreme prematurity
AI-generated summary
Ty Lacey was born at 24.2 weeks gestation with Twin to Twin Transfer Syndrome (TTTS) after his co-twin died in utero. His parents explicitly requested full resuscitation and transfer to Sydney. When Mrs Lacey laboured at Wollongong Hospital, Dr W. consulted the Royal Hospital for Women but instead of discussing options with parents as advised, presented them with no options, stating the baby would not be resuscitated. Ty was born alive but died without medical support as his parents watched. The coroner found this a major and fundamental failure—Dr W. overrode the parents' clearly expressed wishes and failed to discuss available clinical options. He was referred to the Health Care Complaints Commission. Recommendations included developing guidelines for managing extremely premature babies in the grey zone of viability, with mandatory parental consultation, informed management plans, and staff training on end-of-life discussions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to consult with parents on resuscitation options
- Overriding parental wishes without discussion
- Presenting no options despite available clinical alternatives
- Artificial rupture of membranes without clear discussion of informed consent
- Staff unprepared for non-resuscitation situation
- Lack of parental education on what to expect with stillbirth and non-resuscitation
- Lack of continuity of care during pregnancy
- Absence of formal guidelines for grey zone viability cases
Coroner's recommendations
- Creation of a guideline for care and treatment of extremely premature babies in the grey zone of viability including gestational limits (23-25 weeks)
- Development of informed management plans prepared after consultation with parents
- Advise parents of their rights concerning treatment, resuscitation and end-of-life decisions
- Parents' wishes on resuscitation and end-of-life decisions to be obtained and considered paramount
- Management plans subject to change at any time after consultation with parents
- Education of parents via information package on high-risk pregnancy stages and what to expect with stillbirth or non-resuscitated births
- Availability of counselling services throughout pregnancy and after birth
- Training of nursing and medical staff on Australian Resuscitation Guidelines, end-of-life discussions and palliative care explanation
- For shared care management between hospitals, ongoing exchange of information including multidisciplinary discussions on patient care
- Review of High Risk Clinic appointment scheduling to improve continuity of care
- Education of staff on accurate recording of Morbidity and Mortality meeting minutes with regular audit of compliance
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