Coronial
VIChospital

Finding into death of Mia Rose Iskander

Deceased

Mia Rose Iskander

Demographics

0y, female

Coroner

Coroner Simon McGregor

Date of death

2022-06-18

Finding date

2025-02-20

Cause of death

Complications of ascending uterine infection (Klebsiella pneumoniae) in the setting of premature pre-labour rupture of membranes

AI-generated summary

Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal management during PPROM admission (9-16 June) was appropriate and antibiotics were reasonable for detected organisms. However, critical delays occurred on 18 June during labour: abnormal CTG was first noted at 12:43 pm but Category 1 caesarean decision not made until 2:02 pm (79 minutes later), with agreement about delivery need reached at 1:14 pm. The on-call consultant obstetrician was inadequately involved in decision-making and was not present at delivery. Additional delays occurred between decision (2:02 pm) and theatre commencement (3:31 pm) due to waiting for blood results and fasting confirmation, and a junior doctor was permitted to attempt spinal anaesthesia during an obstetric emergency. Escalation failures and inadequate senior involvement contributed to management deficiencies, though the overwhelming foetal infection may not have been preventable despite earlier delivery.

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Specialties

obstetricsneonatologyanaesthesiamidwiferypathology

Error types

diagnosticdelaycommunicationsystemprocedural

Drugs involved

amoxicillinerythromycinbenzylpenicillinceftriaxonecotrimoxazolemetronidazolebetamethasoneadrenaline

Clinical conditions

premature pre-labour rupture of membranes (pprom)chorioamnionitisascending uterine infectionneonatal sepsisfoetal hypoxiafoetal distressneonatal pneumoniasevere respiratory and metabolic acidosiscervical incompetence with cerclagebacterial vaginosisgroup b streptococcus colonisation

Procedures

emergency caesarean sectionspinal anaesthesia attemptgeneral anaesthesiaintubationcardiopulmonary resuscitationintravenous accesscervical cerclage insertioncerclage removalumbilical cord blood gas samplingautopsy

Contributing factors

  • chorioamnionitis with foetal inflammatory response
  • umbilical cord vasculitis and funisitis
  • neonatal pneumonia
  • delays in decision-making for emergency caesarean section
  • inadequate involvement of consultant obstetrician
  • high workload in birth suite delaying registrar attendance
  • delays in transfer to theatre pending blood results and fasting confirmation
  • failure to escalate to Code Green when DDI exceeded
  • inadequate supervision of junior anaesthetist during obstetric emergency

Coroner's recommendations

  1. Review caesarean section procedure to include requirements of senior staff being present at Category 1 preterm births
  2. Review caesarean section procedure to include early escalation to Code Green for non-labouring preterm patients with CTG changes
  3. Ensure consultant obstetrician involvement in decision-making for Category 1 emergency caesarean sections
  4. Implement systems to avoid unnecessary delays in theatre transfer for Category 1 cases pending pathology results or fasting confirmation
  5. Review educational practices during obstetric emergencies to ensure clinical risk is adequately mitigated
  6. Review escalation procedures and staffing to address delays caused by birth suite workload
Full text
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