VIChospital

Finding into death of Baby Chloe Lee Kellett

Deceased

Chloe Lee Kellett

Demographics

5y, female

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2009-04-17

Finding date

2015-06-12

Cause of death

Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

AI-generated summary

Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trace but was born in poor condition (Apgar 2/5/7), requiring respiratory support. Necropsy found cerebral hypoxic-ischaemic injury from clinical birth asphyxia, with the insult occurring 6-8 hours before delivery. Clinical concerns: midwives identified multiple CTG decelerations from 11:45 AM onwards but the obstetrician did not share their concerns until 6 PM, delaying expedition of delivery. Communication failure between medical and nursing staff, lack of escalation mechanisms, and delayed recognition of fetal compromise contributed to prolonged intrauterine hypoxia during labour. Had earlier operative delivery been performed when midwives first raised concerns, the outcome may have differed.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricspaediatricsneonatologyanaesthesia

Error types

diagnosticcommunicationdelay

Drugs involved

oxytocindextrosephenobarbitalclonazepaminotropesantibiotics

Clinical conditions

birth asphyxiahypoxic ischaemic encephalopathymetabolic acidosisseizuresmeconium aspirationhypoglycaemiacerebral infarctioncortical necrosis

Procedures

cardiotocographyforceps deliveryintubationumbilical venous catheter insertionperipheral arterial catheter insertionfoetal scalp electrode applicationepidural insertion

Contributing factors

Delayed recognition of fetal compromise by medical staff
Non-reassuring cardiotocogram trace with variable decelerations from commencement of syntocinon at 11:45 AM
Failure of attending doctor to share midwives' concerns about CTG trace
Dysfunctional communication and poor collaboration between medical and nursing staff
Delay in expedition of delivery despite CTG deterioration from approximately 18:00 hours
Approximately 40-minute delay between decision to expedite delivery and actual delivery at 20:19 hours
Cord tightly wrapped around neck once
Small for gestational age baby (birth weight below 10th centile, rendering baby more vulnerable to labour stress)
Possible brief delay in NETS retrieval (though not causally related to death)

Coroner's recommendations

Ballarat Health policies and protocols now appropriately allow for direct communication between nursing staff and a consultant where staff are unable to access medical review or are unhappy with medical input, and this should be commended and maintained
Given the therapeutic window for hypothermia treatment (within six hours of birth) and the potential for progression from mild to moderate encephalopathy, a case can be made for NETS to prioritise babies born in regional areas by initiating retrieval at the first sign of even mild encephalopathy, rather than waiting for progression to moderate encephalopathy

Full text

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