Non-inquest findings into the death of Lucy Campbell

Contributing factors

• Failure to recognise fetal compromise on cardiotocography during labour
• Delayed escalation to medical staff of abnormal CTG findings
• Poor quality CTG trace at times making interpretation difficult
• Reversion from fetal scalp electrode to external transducer between 20:00-21:00 hours
• Prolonged assisted vaginal birth with 3 pop-offs and multiple pulls
• Maternal exhaustion and poor progression in labour
• Group B Streptococcus colonisation in mother
• Less well-defined escalation processes at Ingham Hospital prior to delivery due to recent organisational restructure

Coroner's recommendations

1. Establish formal process for clinicians at THHS Rural facilities to obtain tertiary obstetric and midwifery opinion from TUH, allowing for peer-review and earlier escalation for complex care decisions
2. Apply alarms listed on assisted vaginal birth clinical pathway form within rural facility context and make pathway form accessible in birth rooms
3. Implement mandatory annual simulation training covering CTG interpretation, continuous monitoring during oxytocin use, intrapartum ultrasound, AVB pathway use, complex AVB management, and Fetalink
4. Incorporate Fetalink into formal escalation processes once established at Ingham Hospital to enable peer review of CTG monitoring
5. Ensure staff identification, self-assessment and appropriate escalation of fatigue concerns