Coroner's Finding: WILLMETT Laura Angela

<1y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia

A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a country hospital. Critical failures included: (1) discharge of the mother from hospital on her due date without continuous monitoring; (2) failure to return promptly after being told labour had commenced; (3) poor handover between referring doctor (who suspected uterine rupture/obstructed labour) and receiving doctor; (4) delay in arranging emergency caesarean despite early CTG abnormalities; (5) inappropriate instruction to push when cervix incompletely dilated. The coroner found the death was preventable had the mother remained in hospital with continuous CTG monitoring, returned promptly when advised, received proper clinical handover, or undergone emergency caesarean earlier. Key clinical lesson: VBAC in under-resourced country hospitals requires rigorous adherence to guidelines including continuous monitoring, immediate transfer for any concerning signs, and comprehensive communication between referring and receiving clinicians.