Inquest into the death of Kalotina Galimitakis

0y · Female·acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa

A neonate died from acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa, a rare condition causing vulnerability to catastrophic bleeding. Key clinical lessons include: (1) prenatal screening may be justified when low-lying placenta is identified, to detect this high-risk condition; (2) communication between obstetric and paediatric teams during resuscitation must be clear and explicitly confirmed, as the registrar did not understand critical information about the cord abnormality even though it was mentioned; (3) protocols for alerting key personnel to emergency caesareans must be followed to ensure special care nursery is prepared; and (4) blood gas testing must be prioritized post-delivery to guide management. While the underlying condition was rare and potentially unpreventable, systemic failures in communication and protocol compliance contributed to suboptimal management.