Finding into death of Pippa May Griffiths
Deceased
Pippa May Griffiths
Demographics
0y, female
Coroner
Coroner Audrey Jamieson
Date of death
2018-04-18
Finding date
2021-11-18
Cause of death
Neonatal death in the setting of meconium aspiration
AI-generated summary
A term neonate died from meconium aspiration three hours after spontaneous labour onset. The mother had presented to hospital the previous day with decreased foetal movements and was discharged without comprehensive assessment (no amniotic fluid index measurement). Critically, the admission midwife on labour was unaware of this history, so did not perform continuous electronic foetal monitoring as guidelines required. After meconium-stained liquor was observed, appropriate neonatal resuscitation occurred but the infant could not be resuscitated. The coroner identified that failure to communicate the prior decreased foetal movement history between clinical episodes meant higher-risk intrapartum monitoring was not implemented. The hospital subsequently implemented significant improvements including revised guidelines, admission CTG for all labouring women, prominent flagging of decreased foetal movement history, and enhanced staff education.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Failure to communicate maternal history of decreased foetal movements from antenatal assessment to labour admission assessment
- Absence of continuous electronic foetal monitoring despite recent history of decreased foetal movements
- No amniotic fluid index measurement performed on antenatal presentation despite decreased foetal movements and post-term pregnancy
- Admission midwife unaware of prior presentation with decreased foetal movements
- Meconium aspiration in utero prior to birth
Coroner's recommendations
- Improved communication of antenatal risk factors, particularly decreased foetal movements, to labour admission staff
- Admission CTG monitoring for all women presenting in labour (implemented by hospital on 4 October 2019)
- Revised clinical practice guidelines on foetal surveillance and reduced foetal movements in accordance with Safer Care Victoria and RANZCOG guidelines
- Prompts to highlight history of reduced foetal movements in pregnancy progress notes at front of medical record and on maternity admission checklist
- Ongoing multidisciplinary simulation-based education training on assessment and management of reduced foetal movements
- Annual staff competency assessment on foetal surveillance consistent with RANZCOG guidelines
- Multidisciplinary education and training on neonatal resuscitation including escalation of care and MET call initiation
Full text
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