Finding into death of Mia Rose Iskander

0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the setting of premature pre-labour rupture of membranes

Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal management during PPROM admission (9-16 June) was appropriate and antibiotics were reasonable for detected organisms. However, critical delays occurred on 18 June during labour: abnormal CTG was first noted at 12:43 pm but Category 1 caesarean decision not made until 2:02 pm (79 minutes later), with agreement about delivery need reached at 1:14 pm. The on-call consultant obstetrician was inadequately involved in decision-making and was not present at delivery. Additional delays occurred between decision (2:02 pm) and theatre commencement (3:31 pm) due to waiting for blood results and fasting confirmation, and a junior doctor was permitted to attempt spinal anaesthesia during an obstetric emergency. Escalation failures and inadequate senior involvement contributed to management deficiencies, though the overwhelming foetal infection may not have been preventable despite earlier delivery.