Finding into death of Dishita Madamshetty
Deceased
Dishita Madamshetty
Demographics
<1y, female
Date of death
2007-09-30
Finding date
2012-07-16
Cause of death
Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioamnionitis/funisitis
AI-generated summary
A full-term neonate born after induction of labour died from hypoxic brain injury secondary to meconium aspiration syndrome and chorioamnionitis. The baby presented in poor condition at delivery with thick meconium present and required resuscitation. Critical clinical lessons include: (1) inadequate CTG monitoring before induction—the abnormal trace was not reviewed for 35 minutes despite appearing pathological from around 0900 hours; (2) failure to increase surveillance after 27 August when amniotic fluid index was low (5.2) with notation of 'minimal' fluid; (3) insufficient responsiveness to maternal presenting symptoms of pain and bleeding at term; (4) lack of awareness of CTG monitoring guidelines among midwifery staff. The coroner found failure to increase foetal monitoring from 27 August or proceed to delivery within 48 hours likely contributed to the death. Better communication between clinicians, clearer protocols for pre-induction CTG review, and heightened vigilance for IVF pregnancies (which carry increased placental complications) could have altered the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Inadequate supervision and delayed review of pathological CTG trace on 30 August 2007 (35 minute delay)
- Failure to increase foetal monitoring after 27 August 2007 when amniotic fluid index was low at 5.2 with notation of 'minimal' fluid
- Insufficient response to maternal presentation with pain and bleeding at term on 23 August 2007
- Lack of clear clinical practice guidelines and time frames for CTG monitoring in PDSU
- Inadequate communication of clinical information between attending clinicians
- Delayed intervention in response to abnormal CTG (90 minutes from abnormal trace to delivery)
- Possible inadequate placental perfusion (progressive rather than acute)
- Chorioamnionitis and funisitis
Coroner's recommendations
- The hospital should adopt and publish formal procedures in relation to CTG monitoring, supervision and oversight to all relevant clinicians
- These procedures should include a requirement for regular monitoring of pre-induction CTG traces (minimum review within 10 minutes of commencement)
- Clinical guidelines should be clearly disseminated to all staff
- Clinicians should ensure all relevant clinical information is available to those providing direct care
- Greater engagement with patients in clinical decision-making should occur, with comprehensive explanation of clinical findings
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