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Daw, Lilly Ella - Non-inquest findings

Deceased

Lilly Ella Daw

Demographics

1y, female

Coroner

McDougall

Date of death

2011-01-30

Finding date

2015-01-29

Cause of death

cystic encephalomalacia

AI-generated summary

Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% risk of neurological injury secondary to twin-twin transfusion syndrome, yet the planned foetal MRI to assess this was never performed. After premature discharge from neonatal care at <36 weeks without documented SIDS counselling or detailed community follow-up, critical clinical information about her high-risk status was not communicated between obstetric, neonatal and paediatric teams. When Lilly presented with a respiratory tract infection and apnoea, there was no documented awareness of her underlying neurological vulnerability. Clinical lessons: ensure multi-disciplinary communication of perinatal risk factors; complete planned neuroimaging in at-risk survivors; provide documented parental counselling on SIDS and discharge planning for vulnerable neonates; maintain awareness of neurological complications in twin survivors.

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

Specialties

obstetricspaediatricsneonatologypathology

Error types

communicationdelaysystem

Clinical conditions

monochorionic diamniotic twin pregnancytwin-twin transfusion syndromeintrauterine foetal deathcystic encephalomalaciafoetal anaemiaparainfluenza type 2 infectionapnoeacyanosis

Procedures

ultrasoundfoetal MRI (planned but not performed)resuscitationneonatal intensive care

Contributing factors

  • intrauterine foetal death of co-twin with twin-twin transfusion syndrome
  • failure to perform planned foetal MRI to assess neurological injury risk
  • lack of communication between obstetric and neonatal teams regarding high-risk status
  • premature discharge from neonatal unit without documented follow-up plan
  • absence of SIDS risk counselling provided to parents
  • co-sleeping with parents
  • maternal smoking during pregnancy
  • respiratory tract infection (Parainfluenza Type 2) in the weeks before death

Coroner's recommendations

  1. Improve multi-disciplinary communication between obstetric and neonatal teams regarding perinatal risk factors and planned investigations for high-risk survivors of monochorionic twin pregnancies
  2. Ensure planned neuroimaging (foetal MRI) is completed for surviving twins at risk of neurological injury from twin-twin transfusion syndrome
  3. Provide documented counselling to parents of at-risk neonates regarding SIDS risk factors and mitigation strategies prior to discharge
  4. Develop and document detailed discharge plans and community follow-up for vulnerable neonates discharged at <36 weeks gestation
  5. Ensure medical staff caring for infants with significant neurological risk are made aware of these vulnerabilities to guide clinical decision-making during acute illness
Full text
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Source and disclaimer

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