Inquest into the death of Georgia Rae Tilmouth

Contributing factors

• Failure to recognize abnormal CTG patterns indicating fetal distress over 7-hour period
• Lack of senior medical supervision of high-risk labour
• Absent registrar from ward after 11:30 am despite high-risk labour
• Only junior resident present for most of labour
• Four-hour gap without vaginal examination during critical period
• Inadequate CTG interpretation by midwives
• Inadequate midwifery supervision due to team leader having own patient load
• Minimal orientation of new midwives to birth suite
• Role confusion between midwife and junior resident
• Inadequate CTG training for midwifery and medical staff
• Student midwives counted in staffing numbers
• Poor documentation and note-taking
• Lack of clarity about management responsibility
• No fetal scalp clip or fetal blood sampling performed despite concerns

Coroner's recommendations

1. The policy regarding the reporting of neonatal deaths to the Coroner needs to be clarified. All staff (obstetric, midwifery and neonatal) need to be aware of the policy regarding reports to the Coroner.
2. Regular senior medical input should occur in the management of high risk labours in the obstetric ward. As a minimum the registrar should be performing labour ward rounds every 4 hours, and in some cases visiting individual patients with high-risk characteristics more frequently.
3. Mandatory education for all staff involved in application and interpretation of electronic fetal monitoring. This must be more than a 'unit expectation' and include all midwives and doctors, not only senior staff. Orientation programs for midwives and doctors must include interpretation of electronic fetal monitoring.
4. Staffing on the Birth Suite must ensure that the team leader/senior midwife is available to support other staff, midwives and doctors. The nurse fulfilling this role cannot also be expected to take a primary clinical load and be responsible for the care of individual women as well.
5. Improved lines of communication between junior medical staff, senior medical staff and midwives in relation to consultation, referral and supervision need to be developed. The lines of accountability and responsibility need to be formalised and an escalation policy developed and implemented.
6. Hospital staff should be reminded, once again, about the importance of note taking both in relation to medical treatment, and in the documentation of requests made by patients in relation to their care.