Coronial
QLDhospital

Glasgow, Benjamin

Deceased

Benjamin Glasgow

Demographics

0y, male

Coroner

Lock

Date of death

2006-10-19

Finding date

2009-03-20

Cause of death

Intrapartum head injuries secondary to brow presentation and obstructed labour

AI-generated summary

Benjamin Glasgow died shortly after emergency caesarean delivery at 12:30 pm on 19 October 2006 for brow presentation, an obstructed labour. Autopsy revealed unprecedented multiple skull fractures and severe brain injury. The labour management was appropriate and timely, with correct decision to proceed to caesarean section. The injuries likely occurred during the manual disimpaction of the foetal head from the pelvis by the obstetrician and assisting midwife. While the coroner identified deficiencies in documentation, handover procedures, and patient communication—criticisms acknowledged as not affecting outcome—the clinical decision-making fell within reasonable medical practice. The coroner did not refer clinicians for disciplinary review but referred the case to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists for educational review of technique refinement and clarification of the assisting midwife's role in such complex deliveries.

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

Specialties

obstetricspaediatricsanaesthesiamidwiferypathology

Error types

communicationsystem

Drugs involved

nitrous oxide

Clinical conditions

brow presentationobstructed labourfoetal head impaction in pelvisintrapartum head injurymultiple skull fracturessevere brain injury with cerebral contusionscord entanglement

Procedures

emergency caesarean sectionmanual disimpaction of foetal headepidural analgesiafoetal scalp electrode placementobstetric ultrasoundcardiotocography (ctg) monitoringinfant resuscitation and intubation

Contributing factors

  • Brow presentation (rare presentation, approximately 1 in 800 deliveries)
  • Foetal head impaction in maternal pelvis
  • Manual disimpaction manoeuvre during caesarean section at full cervical dilation
  • Inadequate handover documentation between covering obstetrician and treating obstetrician
  • Lack of formal verbal handover of patient information
  • Limited communication with patient regarding possibility of caesarean section at 11:25 am before final decision at 11:50 am

Coroner's recommendations

  1. The group practice of Doctors Cheung and Biggs should strongly consider formal handover procedures for recording and communication of patient information when covering each other's patients
  2. Handover processes should include both written documentation and formal verbal handover between clinicians
  3. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists should consider this case as part of its clinical education responsibilities
  4. The College should examine and potentially refine the technique used when assisting with disimpaction of impacted foetal head during caesarean section, particularly regarding the role and technique of the assisting midwife
  5. Clarification of the purpose and method of midwifery assistance in complex disimpaction procedures should be provided through professional education
  6. Hospitals should consider ensuring experienced obstetricians or midwives are available to assist with caesarean sections at full dilation with deeply impacted foetal heads
  7. Clinicians should improve communication with patients during labour, discussing findings and potential management options at 11:25 am rather than delaying to 11:50 am
Full text
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Source and disclaimer

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