Non-inquest findings into the death of Lucy Campbell

Contributing factors

• Failure to escalate fetal compromise on CTG in timely manner
• Deterioration of CTG trace from 2100 hours not escalated to medical staff until after 0138 hours
• Difficult CTG interpretation and poor trace quality
• Lack of real-time monitoring system (Fetalink unavailable at rural facility)
• Possible Group B Streptococcus infection (maternal colonization)
• Organizational changes affecting escalation pathways and supervision structure
• Resource constraints at rural level 3 facility

Coroner's recommendations

1. Establish formal escalation process for rural facilities to obtain tertiary obstetric and midwifery opinion from Townsville University Hospital
2. Make Assisted Vaginal Birth clinical pathway form accessible in rural birth rooms as decision support tool
3. Implement mandatory annual simulation training covering CTG interpretation, continuous monitoring during oxytocin use, intrapartum ultrasound, AVB pathway management, and Fetalink
4. Incorporate Fetalink real-time monitoring system into formal escalation processes once deployed to rural facilities
5. Provide staff training on identification and appropriate escalation of fatigue-related concerns
6. Provide additional training courses including Safety Intervention Essentials, Maternity Emergency Program-Advanced, NeoResus-Advanced, and Fetal Surveillance Education Program