Coronial
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Ely-Smith, Zamia

Deceased

Zamia Ely-Smith

Demographics

3y, female

Coroner

Bentley

Date of death

2018-01-13

Finding date

2021-09-17

Cause of death

Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vaginalis due to rupture of membranes occurring more than eighteen hours prior to birth and subsequent lack of appropriate medical treatment and management in hospital

AI-generated summary

Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospital recommendation for induction should have contraindicated home birth; (2) prolonged rupture of membranes (>18 hours) creates substantial chorioamnionitis risk requiring hospital management, antibiotics, and early delivery; (3) fetal heart rate abnormalities detected during labour (dropping to 77 bpm) demanded immediate ambulance call and hospital transfer per guidelines, not delayed escalation; (4) paramedic resuscitation would likely have been earlier and more effective than midwife-only care; (5) falsification of medical records by both midwives to hide perceived failures prevented accurate clinical assessment. The coroner found the death preventable had appropriate risk stratification and escalation occurred at multiple decision points.

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

Specialties

midwiferyobstetricsneonatologyparamedicinepathology

Error types

diagnosticcommunicationdelaysystem

Clinical conditions

hypoxic-ischaemic encephalopathychorioamnionitisdecreased fetal movementsprolonged rupture of membranesfetal distressGardnerella Vaginalis infection

Procedures

home birthfetal heart rate auscultationneonatal resuscitationpositive pressure ventilation with Neopuffchest compressionsintubation

Contributing factors

  • Decreased fetal movements at 39+ weeks gestation not acted upon
  • Failure to recommend hospital birth despite RANZCOG guidelines after hospital assessment on 7 January
  • Prolonged rupture of membranes (approximately 27 hours) not recognised as contraindication to home birth
  • Inadequate fetal heart rate monitoring during labour - not performed in accordance with guidelines
  • Failure to recognise and act on fetal heart rate abnormalities (FHR dropping to 77 bpm at 3.10am)
  • Delayed ambulance call - called only after birth at 3.40am instead of at 3.10am when FHR distress apparent
  • Falsification of medical records to conceal inadequate fetal monitoring and clinical decision-making
  • Midwife failure to discuss risks of home birth with mother to allow informed decision-making
  • Single clamping of umbilical cord instead of double or triple clamp - prevented cord gas analysis

Coroner's recommendations

  1. Queensland Health consider development of standard guideline for planned home births including: recommendations regarding suitability for home birth; reasons for transfer of mother to hospital during home birth; information sheet compiled with RANZCOG advising of risks of home birth and advantages of hospital birth
  2. Comprehensive list of required equipment for home births including portable CTG monitor and laryngeal mask
  3. Minimum standards for practitioner training including advanced neonatal resuscitation training for all midwives assisting in home births
  4. Emergency checklist for neonatal resuscitation for use by midwives assisting in home births
Full text
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Source and disclaimer

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