Finding into death of Bradley Piper
Deceased
Bradley Keith Piper
Demographics
<1y, male
Date of death
2007-01-26
Finding date
2013-07-02
Cause of death
perinatal asphyxia
AI-generated summary
Bradley Piper was born prematurely (34 weeks) at Kilmore Hospital on 22 January 2007 and died from perinatal asphyxia. Expert evidence established that the hypoxic-ischaemic insult occurred before the last hour of labour, before the delivery was recognised as precipitant. While some care aspects were reviewed (fibronectin test reliance, CTG monitoring gaps, record-keeping), no clinical action at the time could have altered the outcome. The coroner identified lessons for practice: fibronectin testing should be interpreted within full clinical context; hospitals need adequate CTG availability; contemporaneous documentation requires improvement. Transfer to a tertiary hospital was appropriate but timing could not have prevented the pre-labour insult that caused the neurological injury.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- premature labour not identified until approximately 2:45 pm
- precipitate labour could not be predicted
- hypoxic-ischaemic insult occurred before last hour of labour
- gap in CTG monitoring between 3:05 pm and delivery
- inadequate contemporaneous record keeping
Coroner's recommendations
- Education of medical practitioners regarding the consultative role of NETS/PERS, not merely as transfer service
- Hospitals should ensure adequate CTG monitor availability in wards
- Accurate, contemporaneous clinical record keeping must be maintained at all times
- Hospital policy and practice frameworks for structured escalation in clinical concern situations should be implemented
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