Eastern Health has made a number of changes to communication and safety in their infant delivery processes after the tragic loss of a baby a few years ago at Angliss Hospital in Ferntree Gully.
Coroner Dimitra Dubrow has handed down findings on 13 May full-term infant who passed away shortly after birth at Angliss Hospital in August 2022.
“I convey my sincere condolences to Baby W’s family for their loss,” said Coroner Dubrow.
First child to his parents, Baby W, died shortly after birth due to complications arising from a long overnight labour which involved the use of forceps, vacuum assistance and eventually an emergency caesarean section.
Officially investigated as a sentinel event — a preventable death as a result of adverse care, Baby W was born in ‘poor condition’, and attempts to resuscitate the infant by staff were unsuccessful.
Findings from the investigation revealed that the obstetric registrar on duty was not accredited at Eastern Health to independently perform instrumental deliveries and held an unaccredited second-year registrar position, although they were a consultant obstetrician overseas prior to coming to Australia in 2018.
Other issues flagged from the investigation included the lack of documentation around the position of the baby’s head.
“It is clear that the position of the fetal head was not positively identified, which in turn impacted the discussion regarding the birth plan between the registrar and the consultant,” said Coroner Dubrow.
Vaginal examination findings at the birth did not include position and station of the baby’s head and this table was found to be left blank.
The cause of death was classed by the coroner as a subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour, or ruptured veins in the scalp, and stroke.
It was explained through the findings that subgaleal haematoma can occur after difficult vaginal delivery, particularly if there has been a vacuum extractor used.
Eastern Health made a number of changes to its communication, expectations and governance around registrar credentialing and supervision after the sentinel event.
The review panel recommended that all consultants be aware of all the registrars’ current clinical capabilities and the responses required for outside of hours, depending on individual capability, and better awareness in general surrounding employees’ skill set and scope on rosters.
Eastern Health has also referred to a new Safety Bundle for assisted vaginal delivery being trialled at Monash Health which includes a ‘team time out’ prior to assisted delivery taking place and a formal checklist to improve communication as measures to adopt if the trial is found to be effective.
Coroner Dubrow said that this case serves as an important reminder of how critical building and maintaining a safety culture is.
“To contribute to potential statewide and broader learnings, a copy of this finding will be distributed to Safer Care Victoria and Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG),” they said.
