Deceased
Declan Brian McConville
Demographics
0y, male
Date of death
2007-09-08
Finding date
2009-05-28
Cause of death
acute hypoxic damage caused by shoulder dystocia during delivery
AI-generated summary
Declan Brian McConville was born with shoulder dystocia (impacted shoulders) after vacuum-assisted delivery at Royal Darwin Hospital on 31 August 2007. He was stuck in the birth canal for approximately 15 minutes before delivery, causing severe hypoxic brain injury. He died 8 days later from acute hypoxic damage and multiple organ failure. The coroner found the vacuum extraction should have been performed in the operating theatre rather than the birthing suite, allowing easier conversion to caesarean section if needed. Antenatal recognition of the baby's large size (estimated 4.5 kg) through ultrasound could have influenced labour management decisions. The consultant obstetrician was not involved in the decision to proceed with the difficult rotational vacuum delivery despite indicators of complexity. While not critical of individual clinicians' actions, the coroner identified systemic issues: lack of routine theatre access for complicated deliveries, inadequate quality assurance processes, and absence of formal credentialing for registrars. The coroner strongly recommended trials of instrumental delivery be conducted in theatre with mandatory consultant involvement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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