Finding into death of Malakai Cross-De Jesus

Contributing factors

• Decision to proceed with instrumental delivery in birthing suite rather than operating theatre
• Multiple red flags not prompting escalation: fetal malposition, failed forceps application on first attempt, fetal bradycardia with manual rotation
• Delayed recognition of subgaleal haemorrhage (identified between 3-5 hours after birth rather than in first 2-4 hours)
• CPAP bonnet obscuring scalp assessment and preventing early detection
• Absence of formal scalp observation protocol and checks in first critical hours
• Confirmation bias in differential diagnosis: focus on sepsis rather than haemorrhagic shock
• Loss of situational awareness during resuscitation without structured pause/reassessment tool
• Lack of escalation to consultant obstetrician for second opinion despite multiple warning signs
• Prolonged second stage of labour (>2 hours with abnormal CTG) not prompting transfer to theatre for reassessment

Coroner's recommendations

1. That the Royal Children's Hospital formulate a statewide Clinical Practice Guideline (or update the existing 'Blood product prescription' Clinical Practice Guideline) regarding neonatal/paediatric patients who trigger criteria for a massive transfusion protocol response, including the stocking or sourcing of rFVIIa (NovoSeven)
2. Targeted education on subgaleal haemorrhage within NICU encompassing assessment, recognition, best practice management, appropriate choice of headgear and escalation (implemented by Western Health)
3. Expand non-technical skills component of in-situ simulation training within NICU including senior medical staff to improve situational awareness and embed resuscitation pause tools to reduce confirmation bias (implemented as RESQUE tool)
4. Complex forceps delivery including high head with manual rotation will be undertaken in the operating theatre by suitably credentialled and experienced clinician(s) (implemented)
5. Critical Bleeding and Massive Transfusion Protocol reviewed for specific level 6 NICU requirements (implemented)
6. Interdepartmental simulations to test Critical Bleeding and MTP to improve system responsiveness (completed)
7. Return to paper-based workflows in NICU for emergency situations rather than EMR-dependent documentation (implemented)
8. Clinical interviews following serious adverse patient safety events to be formally scheduled for all clinicians as close as possible to time of event
9. Promote awareness and accessibility of existing guidelines relating to incident support and clinical debrief following serious clinical events