Paudel, Preston

Contributing factors

• Inadequate interpretation of CTG tracing by consultant at 0900 review
• Failure to perform fetal blood sampling despite clinical indication
• Failure to escalate care and perform caesarean section when clinically indicated
• Inadequate communication between medical and midwifery staff
• Absence of documented management plan
• Failure to conduct medical review at 0200 despite discussion of potential caesarean
• Delayed vaginal examination at 0550 despite suspicious CTG at 0450
• Failure to assertively communicate concerns from junior registrar to consultant
• Prolonged labour (12 hours syntocinon) with little progress
• Meconium-stained liquor not escalated appropriately
• Absence of CTG monitoring record between 0900 and next day
• Hierarchical culture preventing junior staff from escalating concerns
• Small for gestational age infant (increased vulnerability)

Coroner's recommendations

1. Queensland Health should implement the CTG assessment sticker at all hospitals throughout the State
2. Hospital should implement a policy that four-hourly reviews of high-risk patients be conducted by registrars or consultants
3. Root Cause Analysis processes should ensure relevant members of treating team are interviewed if willing and provided with feedback on outcome, including staff no longer at the hospital
4. Hospital should clarify who is responsible for conducting hourly reviews of CTG traces
5. Hospital should continue to audit compliance with CTG sticker hourly review procedure
6. Hospital should ensure all staff receive graded assertiveness training as recommended in RCA
7. Hospital should consider ways to enable midwives to complete documentation contemporaneously
8. Hospital should audit team leader activities on shift to ensure adequate time for CTG sticker reviews and supervision
9. Continue implementation and monitoring of RCA recommendations, particularly K2MS training and CTG sticker completion
10. Referral of Dr G.'s supervision performance to RANZCOG for consideration