Coronial
VIChospital

Finding into death of William Grant Keays

Deceased

William Grant Keays

Demographics

male

Coroner

Coroner Audrey Jamieson

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.

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Specialties

obstetricsneonatologyanaesthesiamidwifery

Error types

communicationdelaysystemdiagnostic

Drugs involved

oxytocincastor oiloxygenadrenalinesodium bicarbonatedextrosegelofusin

Clinical conditions

intra-uterine asphyxiafoetal distresshypoxic brain injurymetabolic acidosisischaemic encephalopathymeconium-stained liquor

Procedures

amniotomy (artificial rupture of foetal membranes)cardiotocography (ctg)foetal scalp electrode applicationemergency caesarean sectionspinal anaesthesianeonatal resuscitationintubationcardiac massageintracardiac adrenaline administration

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

  1. 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
  2. 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
  3. 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
  4. RANZCOG to take more proactive role in educating members to adopt universal best practice of continuous CTG monitoring with Syntocinon-induced labour
Full text
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