Finding into death of Baby Emma Folwell Kuno
Deceased
Emma May Folwell-Kuno
Demographics
<1y, female
Date of death
2011-07-30
Finding date
2017-01-30
Cause of death
Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficiency
AI-generated summary
Emma, born 26 July 2011, developed severe hypoxic-ischaemic encephalopathy associated with chronic placental insufficiency and died at 4 days old. Her mother reported reduced foetal movements after 34 weeks' gestation, but inadequate antenatal escalation occurred. At labour onset on 26 July, an abnormal CTG trace was identified but obstetric response was delayed and poorly coordinated. By 5:25pm, obstetric review showed a clearly abnormal CTG pattern warranting emergency caesarean delivery, yet this was not performed until natural delivery occurred at 7:26pm. The coroner found suboptimal antenatal care (static fundal height measurements not escalated), poor communication and collaboration between midwifery and obstetric staff, and inadequate obstetric decision-making during labour. While unable to definitively link management failures to death (hypoxic insult timing unclear), the coroner noted the poor clinical coordination could harm other patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Chronic villitis and foetal thrombotic vasculopathy in placenta causing chronic placental insufficiency
- Intrauterine foetal growth restriction
- Abnormal CTG trace not recognised as requiring immediate caesarean delivery
- Delayed obstetric response to abnormal foetal heart rate pattern
- Poor communication between midwifery and obstetric staff
- Consultant obstetrician left without ensuring clear handover and decision-making
- Static fundal height measurements between 34-38 weeks not escalated for obstetric review
- Inadequate antenatal monitoring despite high BMI and grand multiparity
Coroner's recommendations
- Improve CTG interpretation competency assessment for all clinical staff
- Enhance communication and collaboration protocols between midwifery and obstetric staff
- Implement proper documentation standards for all clinical decisions and handovers
- Establish clear escalation pathways for static foetal growth measurements
- Improve antenatal care protocols for high-BMI and grand multiparous women
- Ensure adequate record-keeping by clinical staff rather than relying on maternal records
- Implement structured handover procedures when medical staff are called away from patients
- Develop guidelines for management of abnormal CTG patterns in labour
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