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Inquest into the Death of Baby B

Deceased

Baby B

Demographics

0y, male

Coroner

Coroner Linton

Date of death

2010-05-09

Finding date

2015-06-08

Cause of death

severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia

AI-generated summary

Baby B suffered severe perinatal asphyxia during a planned home birth and died from hypoxic ischaemic encephalopathy. An obstetrician recommended hospital delivery based on the mother's previous unexplained neonatal emergency. However, Community Midwifery Program midwives, through miscommunication and failure to follow up with the obstetrician, allowed the mother to believe a home birth was approved. Critical failures included: the primary midwife not contacting the obstetrician as requested, the manager neither emailing the obstetrician nor ensuring clear policies were followed, and inadequate documentation. No formal confirmation of the obstetrician's decision was communicated to other healthcare staff. The case highlights the necessity for unambiguous written documentation of high-risk pregnancy decisions and mandatory communication protocols between midwifery programs and medical staff to prevent similar deaths.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsmidwiferyneonatologypaediatricspathology

Error types

communicationsystemdelay

Clinical conditions

perinatal asphyxiahypoxic ischaemic encephalopathyunexplained neonatal emergency in previous pregnancyumbilical cord prolapse (postulated)foetal distress

Procedures

cardiotocographyauscultation of foetal heart rateartificial rupture of membranesneonatal resuscitationintubationmechanical ventilation

Contributing factors

planned home birth contrary to obstetrician recommendation for high-risk pregnancy
failure of midwives to contact obstetrician as specifically requested
failure of midwifery manager to contact obstetrician about birth plan
miscommunication between midwifery staff regarding obstetrician approval
inadequate documentation and accessibility of obstetrician's decision in pregnancy records
misinterpretation of hospital discharge as approval for home birth
lack of formal handover procedures between hospital assessment unit and community midwifery program
failure to follow established CMP policies requiring obstetrician approval for birth setting

Coroner's recommendations

North Metropolitan Health Service should improve the method of recording the result of mandatory obstetric review required by CMP policy so that it is easily accessible for all health professionals in the pregnancy record
The CMP Discharge Form should be amended to include a section confirming the birth plan and the obstetrician who has approved it, as well as a section indicating whether the birth plan should be reconsidered due to any issues identified during MFAU admission

Full text

Official source Archived copy

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