Finding into death of Cai Wheeler-Trow

Contributing factors

• Failed instrumental (forceps) delivery requiring emergency caesarean section
• Traumatic birth resulting in parietal skull fracture
• Subgaleal haemorrhage secondary to birth trauma
• Delay in recognition of severity of subgaleal haemorrhage
• Inappropriate modification of ViCTOR vital sign parameters beyond guideline compliance
• Inadequate monitoring including lack of head circumference measurements
• Insufficient investigation pending PIPER arrival despite prolonged delay
• Limited initial documentation by attending paediatrician
• Delay in communication/re-contact with PIPER regarding extended arrival time
• Extensive intracranial injury beyond subgaleal haemorrhage

Coroner's recommendations

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists should amend the guideline 'Prevention, detection, and management of subgaleal haemorrhage in the newborn' to include a section on the importance of assessing head circumference and scalp observations to assist identify the development of a subgaleal haemorrhage after an instrumental birth.
2. The Royal Australasian College of Physicians should develop a guideline incorporating current knowledge from paediatric clinical practice, peer-reviewed studies such as Colditz et al, and coronial findings to assist paediatricians with identification, management and treatment of subgaleal haemorrhages in newborns.
3. The Royal Children's Hospital PIPER service should continue to develop and implement video conferencing capability with referring hospitals to facilitate visualisation of a baby's condition and assist with assessment and management. In the interim, hospital should consider using video capacity of clinician's mobile phones, laptops and/or iPads until compatible information technology systems can be developed.