Coronial
SAhospital

Coroner's Finding: TRIMBOLI Jayden Tyler

Deceased

Jayden Tyler Trimboli

Demographics

0y, male

Date of death

1998-09-25

Finding date

2001-07-13

Cause of death

hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia

AI-generated summary

Jayden Tyler Trimboli, aged 6 days, died from hypoxic-ischaemic encephalopathy caused by a prolonged fetal bradycardia episode between 11:10pm and 11:50pm on 18 September 1998. The critical failure was that the cardiotocograph (CTG) monitor, which clearly recorded the dangerous deceleration, was not being actively observed by staff. Registered Midwife Scobie, as Shift Coordinator, undertook responsibility for monitoring but failed to check the trace or arrange for someone else to do so. When a student midwife (RN Baker) reported the concerning trace to RM Scobie around 11:50pm-midnight, RM Scobie attributed it to loss of machine contact and did nothing. Prompt action—including patient repositioning or urgent cesarean section—could have potentially prevented the catastrophic injury. The case highlights critical failures in CTG monitoring protocols, staff accountability, and communication of clinical significance to patients.

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

Specialties

obstetricsmidwiferyneonatologypaediatrics

Error types

communicationsystemdelay

Drugs involved

prostaglandin gel

Clinical conditions

fetal bradycardiahypoxic-ischaemic encephalopathycerebral edemafetal distresscord compressioncaval compression

Procedures

cardiotocographyfetal monitoringcranial ultrasoundCT scan of brainelectroencephalogram

Contributing factors

  • failure to continuously monitor or arrange monitoring of active CTG
  • failure of Shift Coordinator to discharge responsibility for CTG oversight
  • failure to act on abnormal CTG trace when reported by student midwife
  • misinterpretation of CTG abnormality as loss of machine contact rather than true fetal distress
  • delay in medical response to abnormal trace
  • inadequate handover of monitoring responsibility between staff members

Coroner's recommendations

  1. Staff should comply with the communication reminding them that if a CTG is in progress, someone must be responsible for observing it either by presence in the room or by remote display, and if continuous presence is not possible, ask for help to watch the CTG or return at regular intervals (e.g. 10 minutes)
  2. New fetal monitoring surveillance system with audible and visual alarms should be installed in all rooms, with visual alarm in patient room and audio-visual alarms at nurses station
  3. Unless continuous fetal monitoring is clinically indicated, CTG monitoring should cease after 20 minutes
  4. When a CTG monitor is being attached, the patient should be advised in general terms how to read it or recognize the significance of an alarm light, so that staff can be summoned if they do not react to the alarm
Full text
Official source Archived copy

Related cases from SA

SAhospital2023-07-28

Coroner's Finding: Searle, Bodhi Leo

0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia

Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…

obstetricsmidwiferydiagnosticcommunication
SAhospital2020-08-04

Coroner's Finding: WILLMETT Laura Angela

0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia

A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a …

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
SAhome2016-01-28

Coroner's Finding: NAPIER Ebony Simone

0y · Female·Blunt head trauma from multiple deliberate blows inflicted by father

Ebony Napier, aged 4 months, died from blunt head trauma resulting from multiple deliberate blows inflicted by her father Bradley Napier-Tucker over several weeks. A critical failure occurred when the South Australian ch…

paediatricsradiologydiagnosticcommunicationcannabis

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.