Coronial
VIChospital

Finding into death of Baby Sidney

Deceased

Baby Sidney

Demographics

0y, male

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.

Specialties

obstetricsneonatologyanaesthesiamidwifery

Error types

diagnosticcommunicationdelaysystem

Drugs involved

oxytocinterbutalinemorphinemidazolamphenobarbital

Clinical conditions

hypoxic ischaemic encephalopathyfoetal bradycardiauterine tachysystolesmall for gestational agefoetal head impactionsevere bilateral cerebral and cerebellar infarctionbrainstem and cervical cord compression

Procedures

induction of labourartificial rupture of membranescook catheter insertionvacuum delivery attemptforceps applicationcaesarean sectiontherapeutic hypothermiaintubation and mechanical ventilation

Contributing factors

  • Failure to appropriately manage uterine hyperstimulation
  • Failure to cease or adequately reduce syntocinon in response to abnormal CTG findings
  • Failure to escalate multiple abnormal CTG findings (bradycardia, tachysystole, variable decelerations) to senior consultant
  • Consultant obstetrician absent from mandatory 5pm handover without formal telephone briefing
  • Delay in caesarean delivery following foetal bradycardia and Code Green call
  • Difficult delivery with head impaction in pelvis during attempted vaginal delivery
  • Small for gestational age foetus with maternal concern for decreased foetal movements

Coroner's recommendations

  1. Royal Women's Hospital implement ongoing training to medical staff to appropriately identify risks and address difficulties from disimpaction of the foetal head during deliveries
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