Coronial
VIChospital

Finding into death of Vanessa Li

Deceased

Vanessa Li

Demographics

4y, female

Coroner

Coroner Paul Lawrie

Date of death

2017-01-06

Finding date

2023-10-20

Cause of death

subgaleal haematoma complicating an obstructed labour

AI-generated summary

Vanessa Li, a term infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who was not physically present for much of the early labour. A caesarean section was performed for obstructed labour with the fetal head in occipito-transverse position. Vanessa was born in poor condition (APGAR 2/10 at 1 minute) and required resuscitation. Dr D., the attending paediatrician, documented concern about possible SGH but did not clearly communicate this risk to the PIPER retrieval team during handover. The SGH was not identified until 7.30am, approximately 6 hours after birth. Earlier recognition and aggressive blood pressure support may have prevented deterioration, though outcome was likely poor. Key lessons: always communicate suspected SGH to retrieval teams; maintain high index of suspicion after difficult deliveries; monitor head circumference and blood pressure closely in at-risk infants; obtain cord blood gases in poor condition births.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsneonatologypaediatricsretrieval medicine

Error types

communicationdiagnosticdelay

Drugs involved

oxytocinepidural analgesiabenzylpenicillingentamicindopaminedobutamineadrenalinemorphine

Clinical conditions

obstructed laboursubgaleal haemorrhagehypoxic ischaemic encephalopathyneonatal meningitisdisseminated intravascular coagulationintrapartum asphyxiahypovolemic haemorrhagic shocksevere anaemiametabolic acidosis

Procedures

caesarean sectionforceps applicationmanual rotation of foetal headexternal versioncardiopulmonary resuscitationintermittent positive pressure ventilationumbilical vein cannulationumbilical artery cannulationintubationblood transfusion

Contributing factors

  • obstructed labour with fetal head in occipito-transverse position
  • difficult delivery requiring manual rotation and forceps application
  • intrapartum asphyxia
  • failure to communicate concern about possible SGH to PIPER team during handover
  • delayed identification of SGH (not recognised until 6 hours post-delivery)
  • absence of umbilical cord blood gas analysis despite poor APGAR scores
  • inadequate blood pressure support prior to PIPER team arrival
  • lack of serial head circumference measurements
  • possible concurrent neonatal meningitis

Coroner's recommendations

  1. Epworth to ensure umbilical cord blood gas (ideally arterial) or lactate analysis is drawn and analysed to determine degree of hypoxic-ischaemic stress when babies are born in poor condition requiring significant resuscitation, or blood gas within first hour if cord specimen not drawn (Epworth subsequently implemented routine cord lactate sampling on all births as of July 2017, addressing this recommendation)
  2. Both Epworth and PIPER to develop care pathways for diagnosis, monitoring and management of SGH
  3. Both Epworth and PIPER to develop care pathways for early diagnosis and aggressive management of refractory shock
  4. Epworth to implement improved clinical handover processes to PIPER with explicit communication of delivery difficulties and SGH risk factors
  5. PIPER and referring hospitals to develop standard operating procedures clarifying roles, responsibilities and escalation pathways during joint clinical care
  6. Improved documentation of CTG tracings with concurrent recording of maternal observations
  7. Implementation of rectal temperature monitoring when therapeutic cooling is initiated
  8. Fatigue management strategies for PIPER service during periods of high workload
  9. Enhanced staff orientation and training at referring hospitals to support PIPER team procedures
Full text
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