Finding into death of William Grant Keays
Deceased
William Grant Keays
Demographics
male
Date of death
2003-11-02
Finding date
2008-08-15
Cause of death
Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unascertained)
AI-generated summary
William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation to achieve cardiac output. He died 7 hours later from hypoxic brain injury due to intra-uterine asphyxia. Clinical issues included: inadequate informed consent regarding induction necessity and risks; lack of advice about risks of delivery at non-tertiary hospital; obstetrician absent from hospital when Syntocinon commenced (standard practice but contrary to manufacturer recommendations); delayed continuous CTG monitoring until abnormal fetal heart rate detected at 3:45pm by auscultation; 20-minute delay to obstetric review after midwife notification; and 1 hour 10 minute delay to emergency caesarean section. The coroner could not definitively determine if continuous CTG monitoring, earlier obstetric presence, or tertiary hospital delivery would have prevented death, but identified systemic deficiencies in informed consent, physician availability, and fetal monitoring practices.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Induction of labour with inadequate informed consent
- Lack of information provided to parents about risks specific to private hospital delivery
- Obstetrician absent from hospital when Syntocinon infusion commenced
- Absence of continuous CTG monitoring during Syntocinon-induced labour
- Delayed detection of fetal distress (detected by auscultation at 3:45pm, 1 hour 25 minutes after Syntocinon commenced)
- 20-minute delay between midwife notification and obstetrician review
- 1 hour 10 minute delay to emergency caesarean section (need for staff to be called in)
- Delivery at private hospital without on-site specialist resources
Coroner's recommendations
- RANZCOG to prepare an information booklet/sheet about induction of labour including indications, methods adopted, and circumstances for use, and recommend dissemination through members' practices
- RANZCOG in consultation with Department of Human Services and Australian Private Hospitals Association to prepare a booklet addressing issues women should consider when choosing type of hospital for birth
- RANZCOG to play educative role recommending dissemination of information about differences in services between public and private maternity facilities as standard practice by individual obstetricians
- RANZCOG to take more proactive role in educating members to adopt universal best practice of continuous CTG monitoring with Syntocinon-induced labour
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