Coronial
QLDhospital

Paudel, Preston

Deceased

Preston Paudel

Demographics

male

Date of death

2009-10-13

Finding date

2012-10-25

Cause of death

Global hypoxic-ischaemic encephalopathy

AI-generated summary

Preston Paudel, born at 37 weeks gestation after meconium-stained labour with syntocinon augmentation, was delivered severely compromised with Apgar scores of 1-1-1 and died of hypoxic-ischaemic encephalopathy. Multiple clinicians missed critical opportunities to escalate care between 0200 and 1250 hours. Key failures included: inadequate CTG interpretation (particularly at 0900 review), absent or poorly communicated care plans, lack of fetal blood sampling despite clinical indication, failure to escalate to senior staff, and communication breakdown between midwives and doctors. A caesarean should have been performed by 0200 or 0500 at latest. The coroner found clinical management 'clinically unacceptable at many levels'. Root cause analysis identified CTG training deficiencies, communication failures, and inadequate documentation. Implementation of K2 training, CTG assessment stickers, and assertiveness training were recommended.

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

Specialties

obstetricsmidwiferyneonatologypaediatrics

Error types

diagnosticcommunicationsystemdelay

Drugs involved

oxytocin

Clinical conditions

hypoxic ischaemic encephalopathyfoetal distressmeconium aspirationbradycardiavariable decelerationslate decelerationsprolonged laboursmall for gestational agechoroid plexus haemorrhagesubarachnomial haemorrhage

Procedures

cardiotocographyfoetal blood sampling (not performed)vaginal examinationartificial rupture of membranesepisiotomyresuscitationintubationepidural insertion

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
Full text
Official source Archived copy

Related cases

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —