Finding into death of Tyler Reading-Adams

0y · Male·Intrapartum hypoxia due to true knot in umbilical cord with cord wrapped three times around neck causing vascular occlusion

Tyler Reading-Adams died at 95 minutes old from intrapartum hypoxia caused by a true knot in his umbilical cord wrapped three times around his neck. The mother presented at 40 weeks 6 days gestation with spontaneous rupture of membranes and clear liquor. CTG monitoring in ED showed some variable decelerations but no persistent concerning features. Labour progressed normally with intermittent fetal heart rate monitoring in the birthing suite. During the 12-minute second stage, the baby's heart rate declined from 122 to 70 bpm, but this was not considered concerning as delivery was thought imminent. The midwives performed their duties appropriately given the absence of prior diagnosis of cord complications. The coroner found the death was due to an undetectable anatomical anomaly rather than clinical mismanagement, and made recommendations for improved data collection on umbilical cord abnormalities and future antepartum ultrasound screening capabilities.