Coronial
NThospital

Inquest into the death of Kalotina Galimitakis

Deceased

Kalotina Galimitakis

Demographics

0y, female

Date of death

2011-09-07

Finding date

2012-08-27

Cause of death

acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa

AI-generated summary

A neonate died from acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa, a rare condition causing vulnerability to catastrophic bleeding. Key clinical lessons include: (1) prenatal screening may be justified when low-lying placenta is identified, to detect this high-risk condition; (2) communication between obstetric and paediatric teams during resuscitation must be clear and explicitly confirmed, as the registrar did not understand critical information about the cord abnormality even though it was mentioned; (3) protocols for alerting key personnel to emergency caesareans must be followed to ensure special care nursery is prepared; and (4) blood gas testing must be prioritized post-delivery to guide management. While the underlying condition was rare and potentially unpreventable, systemic failures in communication and protocol compliance contributed to suboptimal management.

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

Specialties

obstetricspaediatricsneonatologyintensive care

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

velamentous insertion of umbilical cordvasa previaantepartum haemorrhagefoetal blood lossneonatal depressionhypoxic ischaemic encephalopathysevere anaemia

Procedures

emergency caesarean sectionneonatal resuscitationumbilical venous catheterisationintubationumbilical arterial catheterisation

Contributing factors

  • velamentous insertion of umbilical cord with likely vasa previa
  • failure to identify condition prenatally despite low-lying placenta on 20-week ultrasound
  • communication failure between obstetric and paediatric teams during delivery
  • paediatric registrar did not understand the term 'velamentous insertion' when advised
  • failure to alert special care nursery to emergency caesarean in advance
  • failure to obtain cord blood gases at delivery
  • absence of senior consultant at delivery
  • delayed call for consultant assistance
  • task fixation of paediatric registrar during resuscitation
Full text

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