Robertson, Elsie - Non-inquest findings

0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, secondary to acute chorioamnionitis; underlying cause: Twin to Twin Transfusion Syndrome treated with laser photocoagulation

Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She died 9 hours 43 minutes after birth from combined hypoxic-ischaemic encephalopathy and E. coli sepsis secondary to chorioamnionitis. Critical clinical lessons include: (1) confusion over twin nomenclature delayed resuscitation by 30 seconds to 4 minutes—surviving twins should be clearly identified at delivery using unambiguous language; (2) E. coli chorioamnionitis signs (maternal pyrexia, malodorous baby) required earlier antibiotic administration (target within 30 minutes of birth, actual delay ~3 hours); (3) fragmented handover communication between obstetric and neonatal teams lacked essential clinical history; (4) CTG abnormalities between 22:15-00:00 hours were not adequately escalated to senior staff. While experts concluded the delays did not ultimately change outcome, systematic improvements in labelling, documentation, communication protocols, and earlier antibiotic administration in suspected neonatal sepsis are essential.