Coronial
WAhospital

Inquest into the Death of Ashlee Jade REINDL

Deceased

Ashlee Jade REINDL

Demographics

0y, female

Coroner

Deputy State Coroner Linton

Date of death

2019-10-27

Finding date

2023-07-07

Cause of death

Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis, with meconium aspiration, with a background of delayed maturation of the placenta, in the settings of induced labour for a prolonged pregnancy

AI-generated summary

Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean section, and though resuscitated, she suffered irreversible brain damage and died the same day. The coroner found Ashlee would likely have survived had she been delivered earlier around 7:45 am, rather than at 10:56 am. Critical failures included misinterpretation of CTG abnormalities from 3:30 am onwards, failure to escalate concerns to senior obstetric review until too late, and an apparent 'tunnel vision' focused on achieving vaginal delivery despite slow labour progress and deteriorating fetal condition. The patient herself requested a caesarean section but this was not acted upon. Poor handover communication, inadequate consultant presence on the birth suite (especially during weekend shifts), and inferior online CTG training for midwives contributed to delayed recognition of fetal distress.

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

Specialties

obstetricsmidwiferypaediatricsneonatologyanaesthesia

Error types

diagnosticcommunicationsystemdelay

Drugs involved

oxytocindinoprostoneentonoxmetoclopramideparacetamolamoxicillingentamicinmetronidazoleadrenaline

Clinical conditions

prolonged pregnancyfailed induction of labourslow labour progressfoetal distressvariable decelerations on cardiotocographyfoetal hypoxiachorioamnionitisintrauterine infectionplacental abruptioncouvelaire uterusmaternal fevermaternal sepsismeconium aspirationfoetal acidosisdelayed placental maturationpost-partum haemorrhage

Procedures

induction of labourartificial rupture of membranescardiotocography monitoringvaginal examinationsepidural analgesiafoetal scalp electrode applicationfoetal blood scalp samplingemergency caesarean sectionneonatal resuscitationendotracheal intubation

Contributing factors

  • Delayed recognition and escalation of fetal distress on CTG monitoring from 3:30 am onwards
  • Misinterpretation of abnormal CTG findings by midwives and registrar
  • Failure of senior medical officer to personally review patient despite abnormal CTG and slow labour progress
  • Continuation of Syntocinon infusion despite lack of labour progression and CTG abnormalities
  • Possible uterine hyperstimulation due to excessive oxytocin augmentation
  • Lack of appropriate handover communication regarding overnight CTG abnormalities and patient concerns
  • Failure to perform fetal blood scalp sampling at 7:30-8:00 am when indicated
  • Focus on achieving vaginal delivery despite clinical warning signs (confirmation bias)
  • Inadequate consultant presence and involvement in decision-making
  • Chorioamnionitis and resulting ascending infection following artificial rupture of membranes
  • Delayed administration of antibiotics (not given until 10:10 am despite fever from 2:30 am)
  • Patient's request for caesarean section at 7:45 am was not escalated or acted upon
  • Weekend shift with reduced medical staffing levels
  • Midwifery CTG training reverted to inferior online format rather than face-to-face
Full text
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