Deceased
Baby Sidney
Demographics
0y, male
Coroner
Coroner Audrey Jamieson
Date of death
2020-12-03
Finding date
2025-07-14
Cause of death
Head injury sustained in a difficult delivery including head impaction and caesarean section
AI-generated summary
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell short of acceptable standards due to: failure to appropriately respond to uterine hyperstimulation by ceasing syntocinon; failure to escalate multiple abnormal CTG findings (bradycardia, tachysystole, decelerations) to the consultant obstetrician throughout labour; and absence of the consultant at the mandatory 5pm handover. Earlier caesarean delivery following the first bradycardia episode would likely have been beneficial. The Royal Women's Hospital acknowledged these failures in their root cause analysis. Implementation of mandatory consultant involvement in handovers, improved escalation pathways, and training in fetal head disimpaction techniques are essential preventive measures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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