Finding into death of Noah Cheron-Duncan

0y · Male·Perinatal asphyxia

Noah Cheron-Duncan, a full-term neonate born at Sandringham Hospital on 19 November 2014, died from perinatal asphyxia. Labour was uncomplicated and FHR monitoring appeared reassuring, but no foetal heart rate was detectable after spontaneous rupture of membranes at 7:17am. However, this was not escalated to senior staff and labour progressed rapidly to delivery at 7:37am, when the baby was born in severe distress (Apgar 0/0). Autopsy showed severe uteroplacental hypoxia. The critical failing was failure to recognise and escalate absent foetal heart rate after membrane rupture, despite Royal Women's Hospital protocols mandating escalation. The coroner found insufficient evidence that earlier intervention would have changed the outcome, but acknowledged RWH's admission of failings during the 22-minute period before delivery and subsequent staff education improvements.