Paudel, Preston

Male·Global hypoxic-ischaemic encephalopathy

Preston Paudel, born at 37 weeks gestation after meconium-stained labour with syntocinon augmentation, was delivered severely compromised with Apgar scores of 1-1-1 and died of hypoxic-ischaemic encephalopathy. Multiple clinicians missed critical opportunities to escalate care between 0200 and 1250 hours. Key failures included: inadequate CTG interpretation (particularly at 0900 review), absent or poorly communicated care plans, lack of fetal blood sampling despite clinical indication, failure to escalate to senior staff, and communication breakdown between midwives and doctors. A caesarean should have been performed by 0200 or 0500 at latest. The coroner found clinical management 'clinically unacceptable at many levels'. Root cause analysis identified CTG training deficiencies, communication failures, and inadequate documentation. Implementation of K2 training, CTG assessment stickers, and assertiveness training were recommended.