Finding into death of Baby RMI
Deceased
RMI
Demographics
0y, male
Date of death
2019-12-14
Finding date
2022-09-30
Cause of death
Perinatal hypoxia
AI-generated summary
An 8-day-old neonate died of perinatal hypoxia on 14 December 2019, 8 days after emergency caesarean section. The infant presented with seizures, hypotonia, and severe encephalopathy. Autopsy revealed severe global cerebral injury consistent with antenatal hypoxia, with timing of injury 3-5 days before delivery. The mother had multiple presentations during pregnancy with reduced foetal movements, and investigations including CTGs and ultrasounds were performed. Clinical lessons include the importance of recognising cumulative significance of repeated reduced foetal movement presentations, ensuring comprehensive medical documentation and information-sharing across the obstetric team, and preserving placental pathology for forensic examination. Documentation gaps meant clinicians may not have fully appreciated the cumulative risk from multiple reduced foetal movement episodes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- True knot in umbilical cord with cord wrapped around body
- Antenatal hypoxia likely occurring 3-5 days before delivery
- Multiple presentations with reduced foetal movements not recognised as cumulative risk
- Documentation gaps in medical review progress notes and discharge summaries
- Inadequate information-sharing regarding past presentations for reduced foetal movements
- Elevated amniotic fluid index (29 at 39 weeks gestation) not acted upon urgently
Coroner's recommendations
- AWH should ensure the accuracy of all medical documentation, including the accurate recording of the timing of events, to improve communication and information-sharing between members of a woman's treating obstetric team
- Emphasis on the pivotal importance of placental pathology in instances of perinatal deaths and the need for hospitals to preserve and provide placental pathology for forensic examination
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