Daw, Lilly Ella - Non-inquest findings

1y · Female·cystic encephalomalacia

Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% risk of neurological injury secondary to twin-twin transfusion syndrome, yet the planned foetal MRI to assess this was never performed. After premature discharge from neonatal care at <36 weeks without documented SIDS counselling or detailed community follow-up, critical clinical information about her high-risk status was not communicated between obstetric, neonatal and paediatric teams. When Lilly presented with a respiratory tract infection and apnoea, there was no documented awareness of her underlying neurological vulnerability. Clinical lessons: ensure multi-disciplinary communication of perinatal risk factors; complete planned neuroimaging in at-risk survivors; provide documented parental counselling on SIDS and discharge planning for vulnerable neonates; maintain awareness of neurological complications in twin survivors.