Coroner's Finding: GALEA Lesley Anne
Deceased
Lesley Anne Galea
Demographics
30y, female
Date of death
1999-04-30
Finding date
2002-02-28
Cause of death
respiratory failure related to bronchopneumonia following cerebral anoxia due to amniotic fluid embolism following uterine rupture during labour
AI-generated summary
A 30-year-old woman with a previous caesarean section attempted a trial of vaginal delivery. She received Syntocinon augmentation at 6:45 AM without prior cervical assessment and epidural analgesia at 7:35 AM. No vaginal examinations were performed between 1:00 AM and 9:30 AM despite these interventions. Continuous electronic fetal monitoring was delayed until 8:00 AM. She collapsed at 9:30 AM with amniotic fluid embolism following uterine rupture, suffering catastrophic cerebral hypoxia, cardiac arrest, coagulopathy, and eventual death from bronchopneumonia 4 months later. The coroner found inadequate labor progress assessment, insufficient fetal heart monitoring given multiple risk factors (trial of scar, Syntocinon, epidural), and poor communication between midwifery and medical staff. While the amniotic fluid embolism itself was unpredictable, earlier delivery through appropriate fetal monitoring and labor assessment might have prevented uterine rupture.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate assessment of labour progress before Syntocinon augmentation
- no vaginal examination prior to Syntocinon infusion
- no vaginal examination prior to epidural anaesthesia
- delayed continuous electronic fetal heart rate monitoring
- inadequate fetal monitoring despite trial of scar, Syntocinon use, and epidural anaesthesia
- poor communication between midwifery and medical staff regarding clinical assessment responsibilities
- uterine rupture during labour
- amniotic fluid embolism
- prolonged hypoxic brain injury
- secondary bronchopneumonia
Coroner's recommendations
- The Head of Obstetrics and Gynaecological Department and the Director of Nursing at Flinders Medical Centre should consider whether further guidelines need to be issued, or training needs to be given, to ensure clear understanding between midwifery and medical staff regarding their respective responsibilities and communication protocols to avoid similar misunderstandings in future.
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