Finding into death of Baby W

Contributing factors

• failed instrumental vaginal delivery with sequential vacuum and forceps use
• fetal position not established prior to assisted vaginal birth
• occipito-posterior position unrecognised
• unaccredited registrar performing instrumental delivery without direct consultant supervision
• slow labour progression not recognised as increasing risk of failed delivery
• caput succedaneum masking true fetal station
• discrepancy between documented and reported fetal position
• inadequate communication between registrar and consultant regarding scope of practice
• inadequate escalation by midwifery staff of concerns during instrumental delivery attempts
• lack of awareness among midwifery staff of registrar's credentialling limitations

Coroner's recommendations

1. All consultants must be aware of all registrars' current clinical capabilities and required supervision expectations
2. Executive clinical director to review rosters and directly communicate registrar credentialling level and expectations of consultant presence and response
3. Formal communication from executive level to all medical staff regarding credentialling register access and supervision requirements
4. Revisit measures to build and maintain a highly skilled workforce including re-advertising for medical workforce increase
5. Appointment of medical workforce supervisors to support junior staff development
6. Make registrar credentialling level visible on rosters and during handovers
7. Review medical workforce model including leadership development embedded in senior staff portfolios
8. Ensure fetal position is definitively established prior to assisted vaginal birth using clinical examination and ultrasound if uncertainty exists
9. Implement use of ultrasound to confirm fetal position when uncertainty exists following clinical examination, particularly given 20-70% error rate of vaginal examination alone
10. Consider implementation of Safety Bundle for assisted vaginal delivery including team time out and formal checklist
11. Introduce remote viewing of CTG monitoring
12. Support staff escalation through clear escalation processes and safety culture initiatives
13. All staff must understand scope of practice of junior medical officers and be empowered to escalate when procedures are performed outside credentialled scope
14. Review neonatal resuscitation documentation guidance to clarify adrenaline dosing based on route of administration (intravenous vs endotracheal)
15. State-wide credentialling systems for junior medical staff with portability across Health Districts to support professional development