Inquest into the death of Everett Carleton

0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background of a high-risk pregnancy, incision of the placenta, transection of the umbilical cord and a delayed delivery

Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though this didn't change surgical management. Critical gaps included: absence of continuous fetal monitoring while mother waited in anaesthetic bay (CTG cannot function without power source); inadequate communication between obstetric and neonatal teams regarding cord transection—the NICU team was unaware, preventing deployment of high-risk resuscitation with emergency blood transfusion; and equipment malfunction (dim laryngoscope light) during resuscitation. First-year registrar performed initial surgery alone due to consultant unavailability. Multiple systemic improvements implemented since: portable CTG monitors, team timeout meetings, level 5 resuscitaires, O negative blood availability, and staffing increases.