Ely-Smith, Zamia

3y · Female·Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vaginalis due to rupture of membranes occurring more than eighteen hours prior to birth and subsequent lack of appropriate medical treatment and management in hospital

Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospital recommendation for induction should have contraindicated home birth; (2) prolonged rupture of membranes (>18 hours) creates substantial chorioamnionitis risk requiring hospital management, antibiotics, and early delivery; (3) fetal heart rate abnormalities detected during labour (dropping to 77 bpm) demanded immediate ambulance call and hospital transfer per guidelines, not delayed escalation; (4) paramedic resuscitation would likely have been earlier and more effective than midwife-only care; (5) falsification of medical records by both midwives to hide perceived failures prevented accurate clinical assessment. The coroner found the death preventable had appropriate risk stratification and escalation occurred at multiple decision points.