Hoy, Samara Lee

Contributing factors

• Inadequate admission CTG monitoring (less than 5 minutes instead of required 10+ minutes)
• Failure to commence continuous CTG despite foetal tachycardia at 9:30pm-10:00pm
• Failure to monitor foetal heart rate between 10:00pm-10:30pm
• Delayed call to obstetrician (called at midnight instead of 10:30pm)
• Inadequate response by obstetrician upon arrival - lack of urgency and failure to examine patient
• Inadequate recording and maintenance of medical records
• Alteration of medical records by midwife
• Failure to call paediatrician as required by hospital policy
• Prolonged second stage labour without appropriate intervention
• Inadequate communication with patient regarding urgency and intervention necessity

Coroner's recommendations

1. All women should have access to balanced antenatal information and classes clearly outlining normal and abnormal labour, when intervention may be required and why it may be necessary, with information about risks of intervention and non-intervention
2. Women should have opportunity to discuss labour antenatally with midwife and obstetrician regarding when and why intervention may be required
3. Underlying guiding principle of maternity care should be healthy mother and infant; birth plans should be flexible and couples made aware intervention may be required; not realistic to have birth plan for natural childbirth at all cost
4. Intervention when required should be carefully explained including why necessary, scientific evidence, and appropriate risks and benefits for informed consent
5. Mother refusing intervention despite recommendations should be clearly outlined in antenatal classes and documented both antenatally and during labour
6. All midwives and obstetricians should be familiar with RANZCOG CTG foetal surveillance guidelines, attend regular CTG courses, and attend regular CTG review meetings
7. All maternity units should encourage staff to attend obstetric emergency courses (ALSO/MaCRM/MOET) and neonatal resuscitation workshops
8. Ongoing professional development for midwives to ensure competency in distinguishing normal from abnormal progress and timely appropriate referral to obstetricians
9. All maternity units should have clear guidelines for when midwives should refer to obstetricians
10. All maternity units should have paediatrician or staff capable of intubating babies available at deliveries with meconium, foetal distress evidence, or instrument/caesarean deliveries
11. All maternity units should schedule paid time for staff familiarisation with policies and procedures with formal annual assessment of understanding
12. Admission Policy should direct explanation of CTG monitoring necessity and encouragement to persevere when mother requests removal
13. All hospital policies should include plain language direction drawing attention to abnormal foetal heart rate patterns and direction to consult specialists if abnormal patterns present
14. Regular professional development for medical professionals in communication during stressful situations should be required by professional bodies
15. John Flynn Hospital should assess medical forms for user-friendliness and readability, provide facilities for midwives to maintain forms closer to patients, consolidate forms to reduce duplication, and avoid separate record-keeping systems not integrated with official medical records
16. Birth plans should be re-cast as guide only, not dictating sole delivery method; expectant mothers should be told plans are flexible and need to accommodate safe delivery
17. Dr Doolabh should undertake re-training in ventouse vacuum extraction, ethics, and communication skills
18. Midwife Fankhauser should undertake re-training in CTG use (including when to use), communication skills, ethics, and documentation
19. Ramsay Health Care and John Flynn Hospital should implement Open Disclosure National Standard
20. Hospital should implement plain language policy on amendments to medical files
21. Hospital should implement system requiring senior administrator approval before accessing stored medical files with recording of date, time, and identification of person accessing records