Date of Findings: 28 June 2017
Coroner: John Lock
Inquest Place: Brisbane
Tonkin Date of Death: 6 June 2014
Langley Date of Death: 25 July 2014
The inquests into the deaths of Nixon Tonkin and Archer Langley both involved consideration of complications which had arisen in relation to their births at the Royal Brisbane & Women’s Hospital (RBWH).
Due to the similarity of the circumstances surrounding the deaths of both Nixon and Archer, the individual inquests were held at proximate times so that any preventative recommendations could be made in a more holistic way, taking into account learnings from each.
Nixon Tonkin died shortly after his birth on 6 June 2014 at 38 weeks gestation. Labour had been induced. An obstructed labour was belatedly noted and a decision to proceed to a caesarean section was made. During the caesarean section, considerable difficulty was encountered by the obstetric Registrar in disimpacting the baby’s head out of the maternal pelvis. A midwife was requested to assist and did so by exerting upward pressure with two fingers on the baby’s head. At birth, Nixon was not breathing and resuscitation efforts were immediately commenced and continued for some time. Nixon showed no signs of recovery and was declared deceased.
The autopsy results revealed that:
- Nixon suffered significant head injuries including skull fractures, subdural and subarachnoid haemorrhages and brain swelling.
- The fractures most likely occurred when the two fingers were pushing on the head via the vagina in an attempt to disimpact the head from the pelvis. The pressure from two fingers is relatively focused and more likely to cause fracture than a broader area of application of force.
- Obstructed labour was the underlying cause of Nixon’s head injuries, and that this in turn was caused by the baby being large, which was likely associated with his mother’s gestational diabetes.
The Coroner made the following conclusions:
- The overwhelming clinical opinion was that a caesarean section was not medically indicated. There are a number of factors to be considered with the advantages, disadvantages and risks associated with a vaginal birth and caesarean to be discussed with the parents, which was not done in this case. Whatever the decision made, the consensus of the medical evidence was that given the importance of patient autonomy, the mother’s decision would have been respected and followed.
- Once in labour, Nixon’s mother was in a substantially different position with regard to her ability to exercise her choice for an elective caesarean section. Nixon’s mother was confined to the maternity ward and birth suite. She was at times in pain and distressed. This would have impacted on her ability to communicate clearly and effectively with others. There was also limited access to more senior staff with whom she could discuss an elective caesarean section as an option.
- The midwife was not trained in the correct technique and utilised two fingers pushing against the fetal head rather than a cupped hand, increasing the risk of skull fractures. The Obstetric Registrar did not provide any instruction to the midwife, and had not received practical training in the technique to be used.
- The cause of the deeply impacted fetal head was potentially due to a combination of delays during labour as well as delay in the availability of senior medical staff to assist in the delivery at a crucial time. There were a number of systems issues which contributed to the delays, rather than individual decisions and actions.
- Significant reforms have been implemented at RBWH such that in future, earlier involvement of a Consultant obstetrician during the labour but particularly at the time of delivery, will allow for a better outcome in difficult situations.
Archer Langley died shortly after his birth on 25 July 2014 at the RBWH. Archer’s mother had gone into an induced labour at a gestational age of 39 weeks and six days. However, her labour failed to progress from that time, and some changes were noted indicating possible concerns for the health of the fetus. A decision was made for an emergency caesarean section due to failure to progress. During this surgery signs of obstruction were noted, including impaction of the baby’s head impacting with the pelvis.
Archer had poor tone and poor colour on delivery and initially had no discernible heart rate or oxygen saturation levels. Attempts were made to ventilate Archer with a bag with some difficulties. The decision was then made to intubate him. He was provided high levels of oxygen and high pressure ventilation, however Archer’s oxygen saturation levels did not improve and there was minimal chest wall movement. He was re-intubated twice but showed no significant improvement. Archer continued to deteriorate and despite resuscitation efforts, his condition remained extremely dire and he was soon after declared deceased.
The autopsy results revealed that:
- The cause of death was due to amniotic fluid aspiration. This was consistent with the clinical history of death occurring shortly after delivery, and difficulty ventilating Archer.
- The consensus of the pathology evidence was that amniotic fluid was found in the lungs of Archer with squamous cells such that it was most likely there must have been an event of stress, which caused gasping and aspiration of the fluid deeper into the lungs of the fetus.
- There was no congenital condition which predisposed Archer to this other than an abnormally thin umbilical cord. This feature was significant as this can predispose to stress being placed on the fetus when the cord is compressed during labour such as during a uterine contraction or other incident involving the cord during labour, which is not uncommon.
The Coroner made the following conclusions:
- There were a number of breakdowns in communication between practitioners involved in the care of Archer and his mother.
- The most likely cause of the amniotic fluid aspiration was due to a gasping event, probably associated with the thin umbilical cord predisposing to such an event occurring due to compression of the cord. The timing of the event of aspiration could not be determined with any degree of certainty.
- Accepting these delays were avoidable, the medical consensus could not establish when such a gasping event occurred although some medical opinion stated it was reasonable to suggest delivery closer to the time that the CTG abnormalities were noted would likely have resulted in a better outcome.
- Education should be provided to midwives and medical staff on an ongoing basis on the identification and management of an obstructed labour.
- Consultant review of high risk patients must occur at the bedside, be clearly documented and involve the multidisciplinary team.
- With respect to documentation, escalation, communication and clinical handover:
- Patients who are identified as high risk in the ante-natal period must remain high risk for the duration of the pregnancy and delivery. This status should be clearly documented in the Pregnancy Healthcare Record to ensure that clinical staff maintain awareness of the high risk status when planning care.
- All fields of the intrapartum record must be fully completed.
- Clinical concerns must be escalated and documented appropriately with reviews conducted and documented in a timely manner.
- Medical staff must document all changes in plan of care and include a clear rationale for the change.
- Processes need to be identified to support medical and midwifery staff during busy times to ensure additional resources are available when required.
- The administration of tocolytics should be considered to cease contractions and reduce the risk of a ruptured uterus when a diagnosis of obstructed labour is made.
- All possible interventions as per the ‘Intubated, can't ventilate?’ poster should be utilised when unable to ventilate a successfully intubated neonate.
- Any changes to the patient’s plan of care or issues identified must be documented by medical staff in the Medical and Obstetric Issues Management Plan in the Pregnancy Health Record and the charts were to be randomly audited to measure compliance.
- It is incumbent on those involved in national training programs of obstetricians and midwifes, as well as within teaching hospitals such as RBWH, to ensure there is ongoing training in simulated emergencies such as this event.
- Increased mandatory training in topics such as identifying obstructed labour, the use of Fetal Pillows, simulated emergencies, CTG interpretation and RANZCOG workshops.
- The team must work collaboratively to ensure timely progression through the second stage of labour. Proactive decision making will minimise delays and ensure that any clinical changes are identified and the care plan is updated at the earliest point (random audits of total).