Finding into death of H C
Deceased
HC
Demographics
6y, male
Date of death
2017-08-11
Finding date
2022-07-28
Cause of death
Global cerebral ischaemia secondary to perinatal asphyxia
AI-generated summary
HC was a neonate who died at 6 days old from global cerebral ischaemia secondary to perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons include: (1) continuous CTG monitoring should have been initiated immediately on arrival given documented decreased fetal movements in the week prior; (2) the abnormal CTG at 9:30pm required either fetal blood sampling or expedited delivery, but management was delayed approximately 1.5 hours; (3) communication failures with a CALD patient without interpreter support during labour compromised informed consent and clinical decision-making; (4) the obstetric consultant was not notified of abnormal CTG until 10:45pm despite recognition at 9:30pm; (5) paediatric team notification was delayed. Contributing factors included placental pathology, meconium aspiration, birth trauma, and possibly herpes simplex virus infection. The hospital implemented centralised CTG monitoring, escalation procedures, and culturally sensitive communication strategies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Decreased fetal movements in week prior to labour not prompting continuous CTG monitoring on arrival
- Obstructed labour with prolonged labour duration
- Abnormal CTG from 9:30pm with delayed escalation and delayed consultant notification
- Delay in decision for caesarean section (made at 11:00pm rather than 9:30pm)
- Patient initial refusal of consent compounded by lack of interpreter and communication difficulties
- Delay in fetal scalp electrode application despite recognition of need
- Delay in paediatric team notification
- Placental pathology including hypercoiled umbilical cord, acute chorioamnionitis, and chronic vasculitis
- Meconium aspiration with upper airway obstruction
- Birth trauma with subgaleal haemorrhage
- Herpes simplex virus identified at autopsy
Coroner's recommendations
- Finalise and submit the business case for an African Liaison position at the hospital
- Develop an information package for staff on the roles of support people and how to communicate with them effectively, with guidance on escalation issues impacting safe birthing outcomes
- Documentation on partograms should include all findings to allow accurate assessment and recognition of abnormal labour process
- Consider use of stickers for documentation of abnormal CTG as stipulated in the Intrapartum Fetal Surveillance Clinical Guideline
- Encourage staff to attend the Fetal Surveillance Education Program offered by RANZCOG on a regular basis
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