Inquest into the Death of Baby CJ (Subject to Suppression Order)

Inquest into the Death of BABY CJ (Subject to Suppression Order)

Delivered on :22 August 2017

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

The names of the deceased, the deceased’s immediate family, and any identifying information are suppressed. The deceased is to be referred to as Baby CJ.

Summary : The deceased was born floppy after a prolonged labour, with no signs of respiration and an uncertain heartbeat that was not detected until 10 minutes 28 seconds after birth. Thereafter, no heart rate could be detected.  Extensive efforts were made to resuscitate him but they were unsuccessful and he was declared deceased.

The focus of the inquest was primarily on the events on 15 and 16 March 2014 at Kaleeya Hospital involving the labour and the birth.

The parents of the deceased had three other children. The first child was born by caesarean section and the three subsequent births were all vaginal deliveries.  It was the parent’s preference to deliver the deceased by vaginal delivery.

On 15 March 2014 the deceased’s mother attended at Kaleeya Hospital as her membranes had spontaneously ruptured. She had telephoned the hospital and had been told to come in for an assessment.  She was admitted and examined.  The deceased’s mother remained overnight in hospital before indicating that she wished to be discharged to go home.  Medical records indicated she was discharged from hospital against medical advice and advised to return to the hospital at 4pm that day.  She did not return at 4pm as arranged.  The hospital made several unsuccessful attempts to contact the deceased’s mother to have her return to the hospital.

The deceased’s mother returned to Kaleeya Hospital at about 7am on 16 March 2014, where she was admitted and taken to the delivery suite. The deceased’s parents decided to continue with their original birth plan.  The deceased’s mother experienced prolonged rupture of membranes, which allowed infection to be introduced, as well as uterine rupture during her labour, which was a known complication of her plan to attempt a vaginal birth after previous caesarean section.  Doctors became aware of the possibility the uterine rupture had occurred approximately three hours prior to the birth and recommended an emergency caesarean section delivery.  The deceased’s parents elected to continue with a vaginal delivery.  As labour continued hypoxia, both as a result of the developing infection and the effects of the uterine rupture.  Unfortunately when instruments were used to assist with the birth it was too late for the deceased to recover from the insult she had received.

The Coroner found the deceased died on 16 March 2014 as a result of hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a neonate with prolonged rupture of placental membranes and death occurred by way of natural causes.

The Coroner noted that this case emphasised the need for good communication between expecting parents and doctors prior to, and during, labour, so that informed decisions are made that prioritise the health and safety of the mother and baby and avoid such a tragic outcome.

Catch Words : Communication between medical practitioners and patients : Health and safety of mother and baby when giving birth : VBAC (Vaginal Birth After Caesarean) : uterine rupture : natural causes

Last updated: 30-Apr-2019

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