Coronial
SAhospital

Coroner's Finding: STEMMER Jessica Lee and MAHAR Thomas William

Deceased

Jessica Lee Stemmer and Thomas William Mahar

Date of death

2006-11-26, 2007-04-17

Finding date

2010-07-09

Cause of death

Jessica: disseminated intravascular coagulation following haemorrhage (subgaleal); Thomas: multiorgan failure and coagulopathy following haemorrhage and hypoxia

AI-generated summary

Two neonates died from complications of subgaleal haemorrhage following ventouse extraction. Jessica Stemmer (7 hours old) died from disseminated intravascular coagulation after subgaleal haemorrhage. Thomas Mahar (8 days old) died from multiorgan failure following subgaleal haemorrhage complicated by intrapartum hypoxia. Both deliveries were technically appropriate. Jessica's death may have been preventable: she required urgent blood transfusion which was ordered but not delivered before her collapse—Dr Barnett did not adequately follow up on the delayed transfusion or repeat critical blood tests despite clear evidence of significant bleeding. Thomas's hypoxic insult during labour could have been partially prevented with earlier notification to Dr Sandercock of deteriorating CTG findings, potentially allowing expedited delivery and reduced hypoxia exposure. Clinical lessons include: maintain high suspicion for subgaleal haemorrhage severity despite apparent haemodynamic stability; repeat blood gas and haemoglobin testing regularly; ensure transfusions proceed without delay; communicate abnormal CTG findings promptly and clearly to senior clinicians.

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

Specialties

obstetricsneonatologymidwifery

Error types

delaycommunicationsystem

Clinical conditions

Subgaleal haemorrhageDisseminated intravascular coagulationHypovolaemic shockCoagulopathyIntrapartum hypoxiaHypoxic ischaemic encephalopathyAcidosis (metabolic and respiratory)AnaemiaMultiorgan failurePosterior fossa subdural haemorrhageFoetal distress

Procedures

ventouse extractionepisiotomyblood transfusionfluid resuscitationbag and mask ventilationblood gas testing

Contributing factors

  • Subgaleal haemorrhage following ventouse extraction
  • Delayed blood transfusion in Jessica's case
  • Failure to follow up on blood transfusion request
  • Failure to repeat critical blood testing in Jessica's case
  • Delayed notification of CTG abnormalities to obstetrician in Thomas's case
  • Intrapartum hypoxia in Thomas's case
  • Coagulopathy secondary to haemorrhage and hypoxia
  • Placental abnormalities in Thomas's case
  • Foetal thrombotic vasculopathy in Thomas's case

Coroner's recommendations

  1. The Minister for Health and Medical Board of South Australia should draw these findings to the attention of the wider medical community
  2. The Royal Australasian College of Physicians should draw these findings to the attention of neonatologists
  3. The Royal Australasian College of Physicians should promulgate a College Statement on Prevention Detection and Management of Subgaleal Haemorrhage in the Newborn replicating the RANZCOG document
  4. The College should draw to neonatologists' attention that subgaleal haemorrhages can behave unpredictably with devastating consequences
  5. Clinicians should not rely solely on haemodynamic stability as it may be falsely reassuring
  6. Regular monitoring of acidosis and haemoglobin levels is essential
  7. Upon diagnosis of subgaleal haemorrhage, practitioners should immediately ensure availability of cross-matched blood and fresh frozen plasma for urgent administration
  8. Practitioners should ensure blood transfusions and plasma transfusions are administered without delay
  9. The Minister for Health should transmit these recommendations to Chief Executive Officers of all South Australian hospitals providing obstetric services
  10. The Women's and Children's Hospital should ensure assurances given to practitioners about availability of cross-matched blood are met
  11. Steps should be taken at Ashford and similar Level 2 hospitals to ensure immediate availability of cross-matched blood in quad packs and fresh frozen plasma upon identification of subgaleal haemorrhage
Full text
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