Finding into death of Poppy Louise Habgood
Deceased
Poppy Louise Habgood
Demographics
0y, female
Date of death
2008-07-10
Finding date
2011-12-14
Cause of death
Perinatal asphyxia
AI-generated summary
Poppy Louise Habgood was born at 0100 hours on 10 July 2008 by emergency caesarean section at 42 weeks gestation, weighing 3968g. She was born severely asphyxiated with a heart rate of 60bpm and died at 0126 hours despite resuscitation. The coroner found the death was preventable. Critical failures included: (1) failure to recognise increasingly abnormal CTG patterns from 2250 hours, (2) failure to notify the on-call consultant obstetrician despite clear clinical deterioration, (3) false reassurance from an unusually low foetal scalp lactate result (1.3 mmol/L) clinically inconsistent with CTG findings, and (4) lack of clear communication of management plans to junior staff. Expert evidence accepted that delivery between 2250–2400 hours would likely have resulted in survival. The case demonstrates dangers of rigid guideline application without considering the complete clinical picture.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Delay in progressing labour to delivery after 2250 hours despite persistent non-reassuring CTG trace
- Failure to recognise deteriorating fetal condition after 2250 hours
- Insufficient consideration of entire clinical picture—decisions made on CTG and foetal scalp lactate in isolation without regard to earlier bradycardia, low amniotic fluid, meconium-stained liquor, length of labour, and fetal size
- Failure to notify on-call consultant obstetrician at appropriate time of developing clinical picture
- Lack of clear communication of management plan from senior registrar to junior registrar
- Rigid application of Clinical Practice Guidelines without considering full clinical picture
- Busy birthing suite and Code Blue emergency at Frances Perry House resulting in senior registrar absence from critical decision-making
- False reassurance from unusually low foetal scalp lactate result (1.3 mmol/L) clinically inconsistent with CTG findings
- Inadequate documentation of clinical reasoning and management plans
Coroner's recommendations
- Clinical practice guidelines relating to CTG interpretation should include directive that if CTG trace is abnormal or worrying, either the on-site or on-call obstetric consultant must be notified of trace results
- If foetal lactate sampling is being considered, the on-site or on-call obstetric consultant must be notified of the intention to conduct sampling and the clinical indicators for sampling
- All clinical staff members on the birthing suite, medical or nursing, should be authorised to contact the on-call consultant in the face of concerning clinical developments, with this authority documented and reiterated in all induction programs and in-service training
- Birthing suite patients should be kept informed of the full clinical picture and in circumstances where there are non-reassuring developments, given information regarding birthing options and options the clinicians are considering
- CTG training should be mandatory at induction for all medical and nursing clinicians working on the birthing suite, with refresher training undertaken annually, reiterating that CTG should be interpreted in the context of the entire clinical picture
- The on-site or on-call obstetric consultant must be notified if a medical clinician is required to absent themselves from the birthing suite to attend Code Green and Code Blue calls
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —