Davies, Mia

Contributing factors

• Abnormal CTG trace with reduced variability not acted upon despite clear clinical indications
• Failure to perform fetal blood sampling despite prolonged abnormal CTG
• Inadequate and broken handover communication of management plan
• Absence of clear documented management plan in medical records
• Multiple consultant involvement without clear clinical leadership
• Failure to recognize that standard labour management guidelines should apply despite fetal congenital anomalies
• Suboptimal consultant review and supervision of high-risk labour
• Excessive labour stimulation with syntocinon causing hyperstimulation
• Delay of almost 90 minutes from decision to instrumental delivery to actual birth
• Subgaleal haemorrhage from obstructed labour and instrumentation
• Underlying congenital cardiac abnormality may have reduced tolerance to labour stress

Coroner's recommendations

1. The Hospital should adopt a policy, procedure or practice that at the changeover of shifts between consultants (at 0815 and 1630) a consultant personally review all high risk patients to satisfy themselves of the ongoing management plan and that management is appropriate
2. A management plan should be documented in the Statewide Pregnancy Health Record from the outset, with any changes to the plan documented in the record
3. The Hospital should conduct an audit to ensure that clinicians reviewing CTG traces document their interpretation on the trace itself and in the medical records and note the actions to be taken
4. The Hospital should implement the suggestions made at the Mortality and Morbidity Meeting regarding fetal surveillance education, consultant support, clinical handover procedures, and graded assertiveness training
5. All consultants, registrars and midwives should provide evidence in performance reviews of attendance at RANZCOG training and completion of online RANZCOG modules and K2 program
6. Consultant support should be provided to reduce clinical risks within the obstetric environment
7. Multidisciplinary clinical handovers should occur at 0815 and 1630 with mandatory attendance by incoming and outgoing registrars and covering consultants, and midwifery team leader present to relay midwifery issues
8. Clinical staff should have access to HEAPS training on graded assertiveness and be empowered to escalate concerns to consultants when unsure or unhappy with current management plans
9. Maternal Fetal Medicine specialists should always attend the 0815 handover
10. Maternal Fetal Medicine management plans should be documented clearly in the hand-held pregnancy record with explicit statements that babies with anomalies should be managed according to standard delivery protocols