Deceased
Baby Mabel Windmill
Demographics
0y, female
Coroner
Coroner Jacqui Hawkins
Date of death
2012-10-10
Finding date
2015-07-15
Cause of death
Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of complicated labour
AI-generated summary
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical management decisions. Despite high BMI (48), Mrs Windmill was approved for delivery at a regional hospital without full antenatal risk counselling. During labour, an abnormal cardiotocograph (CTG) trace was inadequately interpreted by the attending locum obstetrician, Dr W., who failed to appreciate the severity of fetal compromise. Critically, Dr W. augmented labour with Syntocinon in the presence of an abnormal CTG—contrary to established guidelines—and delayed caesarean delivery beyond optimal timing. While the immediate cause of death was established infection, earlier delivery before significant fetal hypoxia developed might have improved survival chances. Key learning points include the importance of clear communication of obstetric risks, adherence to CTG interpretation guidelines, and not delaying delivery when clinical indicators warrant escalation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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