Finding into death of Martha Alice Fraser
Deceased
Martha Alice Fraser
Demographics
<1y, female
Date of death
2011-05-30
Finding date
2016-10-06
Cause of death
Intrapartum hypoxia due to breech delivery with head entrapment and associated cord compression
AI-generated summary
Martha Alice Fraser was born on 30 May 2011 following an unplanned home birth in a frank breech presentation. Her mother, Ms Wood, went into spontaneous labour at home but did not reach hospital in time. The delivery involved head entrapment and cord compression leading to intrapartum hypoxia and death. The coroner found that adequate advice was provided about risks and birthing options, but highlighted that the rapidity of labour and delayed hospital notification were critical factors. The coroner concluded the death was preventable—had Ms Wood been in hospital, the baby would likely have survived. Key issues included the adequacy of information about the risks of vaginal breech delivery, the urgency of hospital attendance once labour started, and the accuracy of ultrasound imaging. While Dr S.'s advice and clinical management were deemed adequate, the family's failure to recognise labour urgency and reach hospital in time proved fatal.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Unplanned home birth
- Failure to reach hospital in time
- Unusually rapid labour (under 2 hours from onset to delivery)
- Frank breech presentation
- Head entrapment during delivery
- Delayed recognition of labour onset by parents
- Delay in calling hospital after waters broke
Coroner's recommendations
- The coroner's recommendation(s) are not explicitly stated in the provided finding text, though the finding discusses the need for clearer advice about when to present to hospital in breech deliveries and the importance of assessing whether formal obstetric ultrasounds at 36-37 weeks should be standard practice for vaginal breech birth candidacy.
Full text
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