Coronial
QLDhospital

Robertson, Elsie - Non-inquest findings

Deceased

Elsie Robertson

Demographics

0y, female

Coroner

Lock

Date of death

2012-10-08

Finding date

2016-02-22

Cause of death

Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, secondary to acute chorioamnionitis; underlying cause: Twin to Twin Transfusion Syndrome treated with laser photocoagulation

AI-generated summary

Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She died 9 hours 43 minutes after birth from combined hypoxic-ischaemic encephalopathy and E. coli sepsis secondary to chorioamnionitis. Critical clinical lessons include: (1) confusion over twin nomenclature delayed resuscitation by 30 seconds to 4 minutes—surviving twins should be clearly identified at delivery using unambiguous language; (2) E. coli chorioamnionitis signs (maternal pyrexia, malodorous baby) required earlier antibiotic administration (target within 30 minutes of birth, actual delay ~3 hours); (3) fragmented handover communication between obstetric and neonatal teams lacked essential clinical history; (4) CTG abnormalities between 22:15-00:00 hours were not adequately escalated to senior staff. While experts concluded the delays did not ultimately change outcome, systematic improvements in labelling, documentation, communication protocols, and earlier antibiotic administration in suspected neonatal sepsis are essential.

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

Specialties

obstetricsneonatologypaediatricsanaesthesiamidwifery

Error types

communicationsystemdelaydiagnostic

Drugs involved

magnesium sulphatecorticosteroidsprophylactic antibioticsadrenalineantibiotics

Clinical conditions

twin-to-twin transfusion syndromespontaneous rupture of membranesacute chorioamnionitise. coli sepsise. coli pneumoniafunisitishypoxic ischaemic encephalopathyfoetal bradycardiaintra-partum asphyxiaprematurityneonatal sepsis

Procedures

fetoscopic laser ablationcaesarean sectionspinal anaesthesianeonatal resuscitationintubationventilationcardiac compressionsumbilical catheter insertion

Contributing factors

  • Twin-to-Twin Transfusion Syndrome
  • Fetoscopic laser ablation procedure at 23 weeks
  • Spontaneous rupture of membranes at 28 weeks
  • Maternal pyrexia and acute E. coli chorioamnionitis
  • Fetal bradycardia (persistent, worsening from ~100 bpm to 40 bpm)
  • Intra-partum asphyxia
  • Prematurity (30 weeks gestation)
  • Confusion over twin nomenclature causing resuscitation delay
  • Fragmented clinical communication and incomplete handover
  • Inconsistent twin labelling practices
  • Delay in antibiotic administration to neonate
  • Pathological CTG not adequately escalated

Coroner's recommendations

  1. Establish single, consistent, standardised process for labelling multiple foetuses in utero
  2. Update hospital policy on twin nomenclature and communicate to all clinical staff including visiting medical officers
  3. Create comprehensive summary/problem page for complex patients detailing clinical risk management plans
  4. Develop single integrated health record for maternity care with clinical cues and forcing functions
  5. Ensure CTG data is entered into electronic system (Guardian) with automated flagging of pathological traces
  6. Implement category 1 Caesarean section notification protocol: neonatal team code call immediately upon decision, team attends theatre for briefing by obstetrician
  7. Integrate neonatal team briefing into Obstetric Surgical Safety Checklist
  8. Maintain antenatal ward list of high-risk women likely to require neonatal admission with brief clinical summary
  9. Ensure early neonatal unit notification when women enter preterm labour
  10. Establish direct communication system between obstetrician and neonatal team in operating theatre
  11. Ensure neonatal consultant present at delivery or on way from home for high-risk cases
  12. Prioritise antibiotic administration within 30 minutes of birth in suspected neonatal infection
  13. Use clear, unambiguous language when identifying infants in multiple pregnancies at delivery
  14. Ensure complete handover of clinical history (including which twin is viable, estimated weights, duration of fetal demise) to all involved clinicians
Full text
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