Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischaemic encephalopathy, result of brain injury as a consequence of complicated assisted vaginal birth

Lucy Campbell, a neonate born on 16 February 2024, died from severe hypoxic ischaemic encephalopathy following a complicated assisted vaginal birth at a rural level 3 hospital. The mother underwent induction of labour at Ingham Hospital following term prelabour rupture of membranes. During labour, fetal compromise on cardiotocography (CTG) was not recognised and escalated to medical staff until late in the labour process. Expert opinion indicated that if CTG deterioration had been recognised by 22:30 hours and escalated to medical staff, earlier delivery may have been possible, potentially improving the outcome. The mother was also Group B Streptococcus positive, which may have contributed to fetal compromise. Key clinical lessons include the importance of timely CTG interpretation, early escalation to senior medical staff when abnormalities are identified, and clear escalation pathways in rural maternity services. The hospital implemented comprehensive recommendations including formalised escalation procedures, mandatory simulation training, and Fetalink implementation.