Demographics
0y, female
Date of death
2022-01-26
Finding date
2023-08-02
Cause of death
Intrapartum asphyxia refractory to postpartum resuscitation due to amniotic fluid and meconium inhalation/aspiration
AI-generated summary
A term neonate died one hour after emergency caesarean section for fetal distress, caused by intrapartum asphyxia due to meconium aspiration. While labour induction, oxytocin dosing, and emergency surgery were appropriately managed, the coroner identified deficiencies in CTG trace interpretation by clinical staff from 12:40 am onwards, when clear signs of fetal compromise were evident. The timing of meconium aspiration could not be precisely determined. Although CTG interpretation weaknesses may not have altered the outcome, the coroner found them concerning and recommended mandatory Foetal Surveillance Education Program certification for all medical staff, recertified every two years, and implementation of remote CTG interpretation technology. Additionally, the coroner noted that a registrar's inability to independently commence emergency caesarean section without consultant attendance warrants review of experience requirements for night duty registrars.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
0y · Male·global hypoxic ischaemic encephalopathy
A term breech baby was born at Launceston General Hospital following a traumatic vaginal delivery with instrumental assistance after failed initial extraction attempts. The infant suffered severe hypoxic-ischaemic enceph…
Female·neck and chest injuries from motor vehicle crash
Sarah Jane Paino, 33 weeks pregnant, died from massive neck and chest injuries sustained in a motor vehicle crash in Hobart on 22 January 2016. An unlicensed 15-year-old driver operating a stolen vehicle at twice the spe…
0y · Male·extreme prematurity associated with acute chorioamnionitis
A 23-week gestation infant (DF) was born at home in Tasmania and transferred by ambulance to Royal Hobart Hospital with signs of life (sinus bradycardia at 26 bpm). Despite CPR and emergency treatment, the infant died on…
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