Inquest into the death of Georgia Rae Tilmouth

0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum hypoxia/perinatal asphyxia)

Georgia Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contributed to her death. Key failures included: lack of senior medical supervision of high-risk labour (registrar absent after 11:30 am, only junior resident present), failure to recognize abnormal CTG patterns indicating fetal distress over a 7-hour period, inadequate vaginal examinations (4-hour gap at critical time), and poor midwifery supervision due to inadequate staffing and orientation. Contributing systemic issues included role confusion between midwife and junior doctor, inadequate CTG interpretation training, understaffing with student midwives counted in numbers, and unclear care planning. Earlier recognition of CTG changes and expedited delivery could potentially have prevented death.