Finding into death of Pippa May Griffiths

0y · Female·Neonatal death in the setting of meconium aspiration

A term neonate died from meconium aspiration three hours after spontaneous labour onset. The mother had presented to hospital the previous day with decreased foetal movements and was discharged without comprehensive assessment (no amniotic fluid index measurement). Critically, the admission midwife on labour was unaware of this history, so did not perform continuous electronic foetal monitoring as guidelines required. After meconium-stained liquor was observed, appropriate neonatal resuscitation occurred but the infant could not be resuscitated. The coroner identified that failure to communicate the prior decreased foetal movement history between clinical episodes meant higher-risk intrapartum monitoring was not implemented. The hospital subsequently implemented significant improvements including revised guidelines, admission CTG for all labouring women, prominent flagging of decreased foetal movement history, and enhanced staff education.