Coroner's Finding: de-identified LD

0y · Female·Intrapartum asphyxia refractory to postpartum resuscitation due to amniotic fluid and meconium inhalation/aspiration

A term neonate died one hour after emergency caesarean section for fetal distress, caused by intrapartum asphyxia due to meconium aspiration. While labour induction, oxytocin dosing, and emergency surgery were appropriately managed, the coroner identified deficiencies in CTG trace interpretation by clinical staff from 12:40 am onwards, when clear signs of fetal compromise were evident. The timing of meconium aspiration could not be precisely determined. Although CTG interpretation weaknesses may not have altered the outcome, the coroner found them concerning and recommended mandatory Foetal Surveillance Education Program certification for all medical staff, recertified every two years, and implementation of remote CTG interpretation technology. Additionally, the coroner noted that a registrar's inability to independently commence emergency caesarean section without consultant attendance warrants review of experience requirements for night duty registrars.