Finding into death of Noah Cheron-Duncan
Deceased
Noah Cheron-Duncan
Demographics
<1y, male
Date of death
2014-11-19
Finding date
2016-04-19
Cause of death
Perinatal asphyxia
AI-generated summary
Noah Cheron-Duncan, a full-term neonate born at Sandringham Hospital on 19 November 2014, died from perinatal asphyxia. Labour was uncomplicated and FHR monitoring appeared reassuring, but no foetal heart rate was detectable after spontaneous rupture of membranes at 7:17am. However, this was not escalated to senior staff and labour progressed rapidly to delivery at 7:37am, when the baby was born in severe distress (Apgar 0/0). Autopsy showed severe uteroplacental hypoxia. The critical failing was failure to recognise and escalate absent foetal heart rate after membrane rupture, despite Royal Women's Hospital protocols mandating escalation. The coroner found insufficient evidence that earlier intervention would have changed the outcome, but acknowledged RWH's admission of failings during the 22-minute period before delivery and subsequent staff education improvements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to detect foetal heart rate after spontaneous rupture of membranes
- Failure to escalate to senior staff when foetal heart rate not detectable
- Possible concealed antepartum haemorrhage (abdominal tenderness) not assessed by senior midwife
- Severe uteroplacental hypoxia shown on placental histology
- Limited supervision of student midwife by midwife in charge
Coroner's recommendations
- Royal Women's Hospital to continue staff education on recognition and escalation of abnormal foetal heart rate findings
- Review of protocols for senior midwife assessment when FHR not readily detectable
- Review of supervision of student midwives and escalation requirements
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