Finding helanisirianni257 08 dscmitchell

Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ failure due to a large subgaleal haemorrhage probably associated with vacuum extraction delivery

Helani Sirianni, born 8 February 2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extraction procedure itself was appropriately performed. However, critical failures in clinical escalation and recognition occurred: nursing staff failed to alert the obstetrician when the CTG trace deteriorated significantly at 1:50am, delaying delivery by 1 hour 15 minutes; the paediatrician missed early clinical signs of bleeding (vasoconstriction, boggy scalp swelling) 3.5 hours after birth, delaying diagnosis by approximately 4 hours. Although subgaleal haemorrhage is a rare but recognized complication of vacuum delivery, and treatment options are limited, earlier recognition might have prolonged circulatory support. The coroner emphasized the need for improved neonatal observation policies with clear vital sign monitoring triggers, staff education in recognizing blood loss, and robust escalation procedures. The Area Health Service subsequently implemented comprehensive policy improvements.