Finding into death of Poppy Louise Habgood

0y · Female·Perinatal asphyxia

Poppy Louise Habgood was born at 0100 hours on 10 July 2008 by emergency caesarean section at 42 weeks gestation, weighing 3968g. She was born severely asphyxiated with a heart rate of 60bpm and died at 0126 hours despite resuscitation. The coroner found the death was preventable. Critical failures included: (1) failure to recognise increasingly abnormal CTG patterns from 2250 hours, (2) failure to notify the on-call consultant obstetrician despite clear clinical deterioration, (3) false reassurance from an unusually low foetal scalp lactate result (1.3 mmol/L) clinically inconsistent with CTG findings, and (4) lack of clear communication of management plans to junior staff. Expert evidence accepted that delivery between 2250–2400 hours would likely have resulted in survival. The case demonstrates dangers of rigid guideline application without considering the complete clinical picture.