Coronial
VIChospital

Finding into death of Lily Irwin

Deceased

Lily Irwin

Demographics

0y, female

Coroner

Coroner Rosemary Carlin

Date of death

2012-09-25

Finding date

2014-08-28

Cause of death

Sepsis

AI-generated summary

Baby Lily Irwin died of sepsis caused by ascending bacterial infection (Staphylococcus aureus) that developed after spontaneous rupture of maternal membranes 48 hours prior to delivery. The infection caused chorioamnionitis with profound foetal inflammatory response, severely compromising the baby before labour commenced. Clinical lessons: (1) Patients declining evidence-based interventions (antibiotics, continuous CTG monitoring) in high-risk situations must be explicitly counselled about risks and consequences, not assumed to be informed; (2) Chorioamnionitis can develop asymptomatically, particularly with aggressive pathogens like S. aureus; (3) Intermittent foetal heart rate monitoring may provide false reassurance compared to continuous CTG; (4) Professional boundaries are critical—treating colleagues and friends requires explicit documentation of risks, not assumptions of knowledge. Antibiotics administered earlier (at onset of labour rather than 29+ hours post-rupture) had greater potential benefit, though established infection may have been refractory. Continuous CTG would have detected foetal compromise earlier but unclear whether outcome would have changed.

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Specialties

obstetricsmidwiferyneonatologypaediatricsanaesthesia

Error types

diagnosticcommunicationsystem

Clinical conditions

sepsischorioamnionitisfoetal inflammatory response syndromeprolonged rupture of membranesperinatal asphyxiaStaphylococcus aureus infectionsevere acidosismeconium aspirationshoulder dystociafoetal distress

Procedures

forceps deliveryendotracheal intubationchest compressionsumbilical venous catheterisationresuscitation

Contributing factors

  • Ascending bacterial infection (Staphylococcus aureus) causing chorioamnionitis and foetal inflammatory response syndrome
  • Prolonged rupture of membranes (48 hours) without prophylactic antibiotics
  • Lack of continuous CTG monitoring—foetal compromise not detected until late stage
  • Assumption that health professional patient was fully informed despite not understanding rationale for guidelines
  • Blurred professional boundaries: patient was midwife colleague, leading staff to avoid challenging her decisions
  • Possible increased infection risk from water immersion in setting of PROM
  • Delayed medical involvement and assessment due to minimisation of doctor involvement

Coroner's recommendations

  1. Victorian Department of Health Chief Nurse and Midwifery Officer, Midwifery Board of Australia and AHPRA to use baby Lily's case (de-identified) to highlight importance of health professionals maintaining professional boundaries
  2. Victorian Department of Health, Midwifery Board and AHPRA to raise awareness amongst midwives of possibility of serious subclinical infections in case of PROM
  3. Eastern Health to use baby Lily's case (de-identified) as example to staff highlighting importance of safe practice and maintaining professional boundaries
  4. Eastern Health to consider establishing protocols for obstetric management of colleagues or friends
  5. Eastern Health to amend relevant policies to explain importance of prophylactic antibiotics in preventing infection and treating subclinical infections
  6. Eastern Health's Expected Pathways of Care for Pregnant Women policy to be amended to explain what is required by way of 'assessment'
  7. Eastern Health to amend relevant policies to explain why continuous CTG monitoring is preferred over intermittent auscultation, particularly capacity to detect reduced foetal heart rate variability
  8. Eastern Health PROM policy to be amended to align with amended Water Immersion Policy explaining that bathing in case of PROM possibly involves increased risk of infection
Full text
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