Coronial
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Sparreboom, Sophie Claire - Non-inquest findings

Deceased

Sophie Claire Sparreboom

Demographics

0y, female

Date of death

2008-03-30

Finding date

2013-09-05

Cause of death

Cerebral hypoxia due to placental abruption

AI-generated summary

Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pathological CTG changes occurred. Critical delay occurred in decision-making and theatre availability: the caesarean was classified as category 2 at 2125, upgraded to category 1 at 2130, but delivery did not occur until 2209 (79 minutes after the category 1 decision). Two experts opined the 30+ minute delay was unconscionable; Dr K. stated that with theatre alerted by 2100 and delivery by 2130, Sophie would likely have been fine. Contributing factors included inadequate second-theatre staffing protocols on weekends, confusion over urgency categorisation causing delays in opening a second theatre, and failure to escalate paediatric presence. The RCA identified systemic failures in communication and resource allocation rather than individual clinical errors.

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

Specialties

obstetricsmidwiferyanaesthesiapaediatricsneonatology

Error types

systemcommunicationdelaydiagnostic

Drugs involved

oxytocinprostaglandinadrenaline

Clinical conditions

gestational diabetes mellitusplacental abruptionantepartum haemorrhagefoetal distresspathological CTG changesprolonged decelerationscerebral hypoxiasevere mixed metabolic and respiratory acidosispoor apgar scores

Procedures

induction of labourartificial rupture of membranesemergency caesarean sectionfoetal scalp electrode placementattempted foetal blood samplinggeneral anaesthesia for caesareanneonatal intubationneonatal resuscitation

Contributing factors

  • Antepartum haemorrhage with placental abruption
  • Pathological CTG changes from 2050 hours
  • Delay in emergency caesarean section: 79 minutes from category 1 classification to delivery
  • Classification as category 2 at 2125 hours (rather than category 1 immediately when distress became apparent)
  • Inadequate second-theatre staffing availability on weekends
  • Confusion regarding emergency caesarean category system and resource activation
  • Delay in obtaining second operating theatre: categorisation semantics prevented immediate theatre preparation
  • Failure to alert theatre at ~2100 hours when foetal distress was evident
  • Failure to escalate paediatric presence earlier despite clear indicators of high-risk delivery

Coroner's recommendations

  1. Develop business case for increased operating room staffing after hours and weekends to enable second theatre opening within 20 minutes
  2. Implement uniform emergency caesarean category system with prominent display in birthing and operating suites
  3. Establish automated paging system for category 1 caesarean sections to all relevant staff (obstetric consultant and registrar, anaesthetic consultant and registrar, paediatric registrar, nursery, operating theatre coordinator)
  4. Develop workplace instructions for emergency caesarean categorisation with version controls
  5. Develop workplace instruction for optimising care of critically ill neonates with assessment by on-call senior registrar or consultant
  6. Institute protocol for theatre alerting when foetal distress is evident (not waiting for formal category 1 decision) to enable timely theatre preparation
  7. Ensure CTG machine availability in operating theatre for continuity of tracing during emergency caesarean
  8. Implement second on-call team availability after hours and weekends (second theatre registered nurse, second on-call anaesthetist)
  9. Ensure obstetrician and anaesthetist directly communicate regarding decision to open second theatre
  10. Implement electronic theatre booking form with separate section for clinical priority rating
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