Finding into death of Cai Wheeler-Trow

0y · Male·Head injury in the setting of labour

Baby Cai Wheeler-Trow was born at 36 weeks and 2 days following a failed instrumental delivery and emergency caesarean section. He developed a skull fracture and subgaleal haemorrhage, presenting with clinical deterioration at approximately 4 hours of age. The coroner found that while Dr M.'s initial assessment was understandably difficult (subgaleal haemorrhages are rare and insidious), critical gaps existed: inadequate head circumference monitoring, inappropriate modification of vital sign thresholds on the ViCTOR chart, insufficient investigation pending PIPER arrival despite 90+ minute delay, and documentation below expected standards. The coroner could not definitively establish preventability due to extensive additional intracranial injury, but emphasized the importance of anticipating subgaleal haemorrhage risk after traumatic delivery, maintaining appropriate monitoring parameters, and ensuring prompt investigation and escalation.