Coroner's Finding: KROL Riley

Contributing factors

• sustained foetal bradycardia lasting approximately 30 minutes post-ARM
• delay of 90 minutes from decision to emergency caesarean section to delivery
• absence of on-duty theatre staff
• absence of on-duty anaesthetic consultant
• junior anaesthetic registrar without permission to administer general anaesthesia unsupervised
• unsuccessful attempts at spinal anaesthesia by both junior registrar and consultant
• selection of time-consuming epidural anaesthetic instead of general anaesthetic
• inadequate communication of clinical urgency to consultant anaesthetist
• consultant anaesthetist not informed of duration and significance of prior bradycardia
• consultant anaesthetist not informed of limited reassurance from improved heart rate
• failure of obstetric registrar to explicitly request general anaesthesia from consultant
• maternal obesity (BMI 36) presenting technical challenges for spinal anaesthesia
• no epidural in situ prior to labour for expedited induction of anaesthesia

Coroner's recommendations

1. The Minister for Health should cause a review to be undertaken in respect of hospitals providing obstetric services regarding their capability of responding appropriately and timeously to emergency caesarean section procedures, with particular regard to: (a) existence of emergency protocols; (b) availability of operating staff at night; (c) availability of suitably qualified and experienced clinicians capable of performing general anaesthesia.
2. The Minister for Health should implement measures designed to facilitate efficient and expeditious carrying out of emergency caesarean section procedures following such review.
3. Any hospital providing obstetric services should have anaesthetic registrars on duty during night shifts who are of suitable seniority and experience to administer or commence general anaesthesia when required.
4. On-call anaesthetic consultants should be sufficiently proximate to obstetric hospitals to enable attendance at short notice.
5. Emergency protocols for obstetric caesarean sections should clearly define urgency categories (such as Category 1 for immediate threat to life) to facilitate appropriate communication between obstetric and anaesthetic teams.
6. Robust communication protocols should ensure that obstetric registrars explicitly communicate the degree of clinical urgency to anaesthetic staff when requesting specific anaesthetic techniques.
7. Women with body mass index greater than 35 undergoing labour induction or at higher risk of emergency caesarean section should be referred for antenatal anaesthetic assessment and should consider epidural insertion during labour to enable expedited anaesthesia if emergency caesarean becomes necessary.
8. Anaesthetic consultants arriving at emergency caesarean sections should be briefed on the duration of foetal bradycardia and the significance of CTG tracings, not merely told a general caesarean section is 'urgent'.