Deceased
Emma May Folwell-Kuno
Demographics
0y, female
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2011-07-30
Finding date
2017-01-30
Cause of death
Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficiency
AI-generated summary
Emma, born 26 July 2011, developed severe hypoxic-ischaemic encephalopathy associated with chronic placental insufficiency and died at 4 days old. Her mother reported reduced foetal movements after 34 weeks' gestation, but inadequate antenatal escalation occurred. At labour onset on 26 July, an abnormal CTG trace was identified but obstetric response was delayed and poorly coordinated. By 5:25pm, obstetric review showed a clearly abnormal CTG pattern warranting emergency caesarean delivery, yet this was not performed until natural delivery occurred at 7:26pm. The coroner found suboptimal antenatal care (static fundal height measurements not escalated), poor communication and collaboration between midwifery and obstetric staff, and inadequate obstetric decision-making during labour. While unable to definitively link management failures to death (hypoxic insult timing unclear), the coroner noted the poor clinical coordination could harm other patients.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Court Reference: COR 2011 002845
Form 37 Rule 60(1)
Section 67 of the Coroners Act 2008
Inquest into the Death of: Baby Emma FOLWELL KUNO
Delivered On:
Delivered At:
Hearing Dates:
Findings of:
Representation:
Police Coronial Support Unit
30 January 2017
Coroners Court of Victoria 65 Kavanagh Street Southbank Victoria 3006
Mention: 6 September 2013 Inquest: 4-8 and 18 August 2014 Submissions: 20 February 2015
Coroner Paresa Antoniadis SPANOS
Mr J. BRETT of Counsel, instructed by Anne Shortall of Salter and Gordon, appeared on behalf of the parents Linda Folwell and Brett Kuno.
Ms F. ELLIS of Counsel, instructed by John Petts of TressCox Lawyers, appeared on behalf of Western Health.
Mr D. O’CALLAGHAN, appeared on behalf of midwives, Susan Budge and Susan Currie.
Leading Senior Constable A. MAYBURY, assisting the Coroner
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I, PARESA ANTONIADIS SPANOS, Coroner, having investigated the death of Baby EMMA MAY FOLWELL-KUNO
and having held an inquest in relation to this death at Melbourne
on 4-8 and 18 August 2014 and 20 February 2015:
find that the identity of the deceased was EMMA MAY FOLWELL-KUNO born on 26 July 2011
and that the death occurred on 30 Fuly 2011
at the Royal Women’s Hospital, 20 Flemington Road, Parkville, Victoria 3052 from:
I(a) HYPOXIC-ISCHAEMIC ENCEPHALOPATHY IN THE SETTING OF CHRONIC
in the following circumstances:
delivery between 1989 and 2008 with birth weights recorded at between 3175 and 4020 grams.”
was recorded as 5.8 centimetres [cm], indicating 12 weeks and two days’ gestation.*
Practice [MGP]. This model of care involves a collaborative approach to maternal care by
' Coronial Brief of Evidence [CB], page 74ff, Health Assessment Maternity History & Examination, ? CB, page 74ff, Health Assessment Maternity History & Examination.
3 Thid.
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c i ' ia
midwives and obstetricians which aims to provide continuity of care for women through pregnancy, birth in a hospital setting and the post-natal period. The Australian College of Midwives’ National Midwifery Guidelines for Consultation and Referral® [Midwifery Guidelines], WH’s Essential Guide to Antenatal Clinic 2010° [WH Antenatal Clinic Guide] and Sunshine Hospital Antenatal Clinic ~ Pregnancy Appointment Checklist” [Antenatal Checklist]
guided practice under this model of care.
4, In the MGP, midwives work with a caseload partner and within a small group practice of six midwives. Each caseload midwife has a caseload of about 40 women each year (three or four patients delivering per month) and is on call for 10 days and seven nights per fortnight, the other seven nights being covered by her® caseload partner. Midwives work within their expertise and are responsible for the care they provide, liaising with obstetricians, paediatricians and other clinicians as a patient’s needs dictate. Where a patient has or develops medical or obstetric risk factors or complications, overall antenatal, perinatal and post-natal clinical decision-making is to
be managed by the obstetric team.”
and, in addition to the routine ultrasound performed to assess foetal morphology at 20 weeks’
gestation, ! ultrasound examinations were performed at 28'4 and 33!° weeks gestation to assess
foetal growth given Ms Folwell’s high body mass index [BMI].'
3 Second edition published in 2008 (appended to Exhibit F) and applicable at the time Ms Folwell was pregnant with Baby Emma.
6 Exhibit N. The 2010 version was revised and replaced in 2014, 7 Exhibit P.
5 Although not all midwives are female, for convenience I have used the female pronoun to refer to ‘midwives’ in general, noting incidentally that in this case, all of the midwives who attended upon Ms Folwell in the material period were female.
9 See generally exhibits E, ¥, N, O and V.
0 Exhibit V.
4 uxhibit O.
2 Ms Folwell’s WH Medical Records [MRs] confirm that she attended seven antenatal appointments with the Midwifery Group Practice on 2 February, 17 March, 19 April, 20 June, and 4, 18 and 25 July 2011.
13 CB, pages 65-66, ultrasound performed on 10 March 2011.
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Interpretation of the features documented by the CTG trace as ‘reassuring’, ‘non-reassuring’ or
‘abnormal’ by midwifery and obstetric medical staff!’ allows early detection of foetal distress
and so informs clinical management.”°
‘4 CB, pages 67-70, ultrasound performed 10 May 2011 [‘May ultrasound’].
'5 CB, pages 71-72, ultrasound performed 17 June 2011 [‘IJune ultrasound’).
16 Body Mass Index [BMI] is an approximate measure of whether an individual is under- or overweight, calculated by dividing their weight in kilograms by the square of their height in metres. BMI values of 18.5 or less indicate that a person is underweight, values between 18.5 and 24.9 indicate a normal/healthy weight, values between 25 and 29.9 indicate the individual is overweight and values greater than 30 indicate obesity. Ms Folwell’s BMI was recorded as 37 in MRs.
‘7 Coronial Brief of Evidence, page 101ff, WH Admission/Discharge Form Sunshine Hospital and Exhibits O and V.
18 A CTG uses ultrasound to detect the foetal heartbeat and uterine contractions during pregnancy and/or labour. The transducers placed on the woman’s abdomen are connected to a monitor that displays the FHR numerically and the FHR is also audible to those nearby. The CTG produces a printed record — or trace — that plots each captured measurement. However, hot all foetal heart beats or contractions will be recorded if there is suboptimal contact between the transducers and the woman’s abdomen and so sometimes a scalp electrode may be applied to the foetus to more directly monitor the FHR. CTG transducers may be removed for short periods, such as to allow the labouring woman to take a toilet break, resulting in a gap in the CTG trace.
'9 Clinicians assess all aspects of the CTG to develop an overall impression (or clinical judgement) of its features as ‘reassuring’, ‘non-reassuring’ or ‘abnormal’, The ability to correctly interpret a CTG trace is a core competency for both midwives and obstetricians.
© The CTG trace enables clinicians to ‘see’ key indices of foetal wellbeing and the progress of labour such as the bascline FHR, variations, accelerations and decelerations of the FIIR and the frequency, duration and apparent intensity of ulcrine contractions. The baseline FHR is the average heart rate of the foetus in a ten-minute period. A normal foctal heart ratc is between 110 and 150 bpm. A degree of variability (variation of the FIIR form one beat to the next) is ' regarded as a good indicator of foetal wellbeing. The amount of variability from the baseline FIIR and its duration may be interpreted as ‘reassuring’, ‘non-reassuring’ or ‘abnormal’. Accelerations are an abrupt increase in baseline heart tale of more than 15 bpm for greater than 15 seconds. Accelerations are considered reassuring and when they occur alongside uterine contractions are seen as a sign of a healthy foetus. The absence of acceleration (in an otherwise normal CTG trace) is of uncertain clinical significance. Decelerations are an abrupt decrease in baseline heart rate of morc than 15 bpm for greater than 15 seconds. There are a number of types of decelerations, each with varying significance. An ‘early deceleration’ starts when a uterine contraction begins and resolves when the contraction ends.
This type of deceleration is considered physiological rather than pathological. ‘Variable deceleration’ is seen as a rapid fall in baseline heart rate with a variable recovery phase; they may be variable in duration and may be unrelated to uterine contractions. Variable decelerations are often seen during labour, in patients with reduced amniotic fluid volume and are often caused by umbilical cord compression. Accelerations before and after a variable deceleration are known as the ‘shoulders of deceleration’ indicating that a foetus is not yet hypoxic and is adapting to reduced blood flow. Variable decelerations can sometimes resolve if the mother changes her position. The presence of persistent variable decelerations should be closely monitored and variable decelerations without ‘shoulders’ is suggestive of foetal hypoxia. A ‘late deceleration’ begins at the peak of uterine contraction and should resolve after the contraction ends.
This type of deceleration indicates there is insufficient blood flow through the uterus and placenta and may produce foetal hypoxia and acidosis. The presence of late decelcrations may indicate further investigation (such as foctal blood.
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7, RNM Budge reviewed the first few minutes of the CTG trace and observed a deceleration of the FHR to 60 beats per minute [bpm], with quick recovery, associated with a mild contraction.2!
Unsure of its significance, she consulted RNM Currie who had just become available to take
over Ms Folwell’s care.”
At about 5.15pm, RNM Currie performed a vaginal examination [VE] with Ms Folwell’s consent to assess her status.*? Ms Folwell’s cervix was 3cm dilated and effaced, with bulging membranes.“ ‘The CTG trace showed that contractions were irregular, mild and occurring at a rate of one every 10 minutes.2> RNM Currie concluded that Ms Folwell
was not in established labour and birth was not imminent.”6
9, The management of Ms Folwell’s labour was the primary focus of the inquest and will be discussed in some detail below. Suffice for present purposes to say that Baby Emma was born at
7.26pm? on 26 July 2011 by a precipitate but normal vaginal delivery! At birth, Baby Emma
weighed 2692 grams, was white and floppy with the umbilical cord looped twice around her
sampling) to determine whether the foetus is hypoxic and/or there is a need for emergency caesarean delivery.
‘Prolonged deceleration’ is a deceleration of more than two minutes’ duration. Decelerations of two-to-three minutes arc considered ‘non-reassuring’ while decelerations lasting more than three minutes are considered ‘abnormal’ and may require clinical intervention.
2 Exhibit O.
22 Thid.
23 Exhibit V.
24 Exhibit V and CB, page 115 (MRs).
25 Exhibit V.
26 Exhibits V and O.
27 Exhibit V.
28 Exhibit O,
29 Exhibits V, E and K.
3 J note that Ms Folwell disputed that Baby Bmma was born at 7.26pm as was recorded in all medical records (Transcript pages 31 52, 54-55). She believed that her daughter was born at 7.22pm (Transcript pages 554-55). Ms Currie and Ms Kay were both also present at the birth. Ms Currie testified that she did not record the time of birth, but noted that the time of birth is an important detail given its relevance to Apgar scores and resuscitation (Transcript page 638). Ms Kay did record the time of Baby Emma’s birth and gave categorical evidence that she was born at 7.26pm, in poor condition, and that the paediatrician was present one minute after birth by which time the midwives were already performing cardio-pulmonary resuscitation (Transcript page 93),
31 CB pages 106-108, Birthing Clinical Summary printed at 9.48 on 26 July 2011.
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neck,*? The cord was cut, a neonatal ‘Code Blue’? was called and active resuscitation
commenced immediately, with oxygen delivered by continuous positive airway pressure [CPAP]
prior to the arrival of a paediatrician at about 90 seconds after birth.*4
established prior to Baby Emma’s transfer to the Special Care Nursery [SCN].°?
32 Exhibit V and CB page 152, Baby Emma’s NETS Medical Records, Perinatal History.
33 The announcement of an emergency situation in a health care setting indicating the need for cardio-pulmonary resuscitation.
44 Exhibit E and Baby Emma’s WH progress notes.
35 The Apgar score allows clinicians to quickly evaluate a newborn’s physical condition. Five factors are cach scored ona scale of 0 to 2 (with 2 being the best score) are used to evaluate the baby’s condition: Appearance (skin colour), Pulse (heart ratc), Grimace response (reflexes), Activity (muscle tone), Respiration (breathing rate and effort), The Apgar test is usually administered at one- and five- minutes after birth. Ten is the highest score possible, but is rarely obtained.
36 | note that there are six different entrics in MRs recording Baby Emma’s Apgar scores and that the recorded scores are not consistent. [ have preferred the scores noted in the text above on the basis that the record of lower scores may represent ‘default’ valucs in the Birthing Clinical Summary record, the expert opinion of Philip Henschke suggests that an Apgar of seven at one minute (recorded elsewhere in the notes) was inconsistent with Baby Emma’s condition at bith and the contextual comments of Dr Bomban amending the Apgar scores she originally assigned on 26 July 2011 in a rctrospective progress note made on 1 August 2011 upon return from sick leave. I note Dr Henschke’s reservations, generally, about the accuracy of the Apgar scores assigned retrospectively six days after Baby Emma’s birth. The various Apgar score notations are as follows: (1) Birthing Clinical Summary printed at 9.48 on 26 July 2011, recording Apgar scores of zcro at onc minute and zero at five minutes (CB pages 106-108); (2) Birthing Clinical Summary printed at 12,23pm on 30 July 2011, recording Apgar scores of seven al one minute and eight at five minutes (CB pages 109111); 3) Birthing Clinical Summary printed at 9.48 on 26 July 2011, with an unsigned hand-written amendment of Apgar scores as seven al one minute and eight at five minutes and eight at ten minutes (CB pages 112-114); (4) Progress note written by Dr Bomban at 7.27pm on 26 July 2011 recording Apgar scores as seven at’one minute and cight at two-to-three minutes (CB pages 133); (5) a further progress note written by Dr Bomban at 10,15pm on 26 July 2011 confirming the scores noted at 7.27pm (CB page 135); and, a retrospective note written by Dr Bomban on 1 August 2011 at 1.20pm ‘correcting’ the Apgars and recording the scores as three at one-and-a-half minutes, five at twoto-three minutes, seven at five minutes and eight at ten minutes after birth (CB page 139),
37 CB page 133, Progress note made by Dr Bomban on 26 July 2011 at 7.27pm.
38 CB page 139, Retrospective Progress note added by Dr Bomban on 28 July 2011 at 4.50pm.
CB page 139, Retrospective Progress note added by Dr Bomban on 28 July 2011 at 4.50pm.
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At onc hour after birth, Baby Emma developed seizures and was provisionally diagnosed with mild hypoxic-ischaemic encephalopathy, neonatal convulsions, respiratory distress, and suspected sepsis. She was treated with ventilation and oxygen therapy, antibiotics,
phenobarbitone and intravenous fluid therapy.*°
On 27 July 2011, a consultation with the Newborn Emergency Transport Service [NETS] was made and therapeutic hypothermia was instituted prior to Baby Emma’s transfer to the Royal Women’s Hospital Neonatal Intensive Care Unit [RWH]. Upon examination at the RWH, Baby Emma scemed hypotonic, with small reactive pupils, a weak gag reflex and no suck reflex. Cercbral function monitoring by electroencephalogram [EEG] was commenced shortly after admission and was found to be severely abnormal, with depressed EEG activity and multiple seizures. Phenobarbitone was administcred to control scizures with good effect. A
cranial ultrasound showed severe cerebral oedema,*!
Later that day, Baby Emma’s oxygen requirements increased and so she was intubated and high frequency oscillation ventilation [HFOV] was administered. An echocardiogram at this time showed poor cardiac contractility and pulmonary hypertension, which were treated with nitric oxide and inotropes and dubotamine. Baby Emma responded well to these
interventions, such that HFOV and nitric oxide were ccased the following day.”
A cranial magnetic resonance imaging [MRI] scan performed on 28 July 2011 showed extensive frontal, parietal, occipital lobe and para-sagittal cortical and white matter infarction associated with basal ganglia and thalamic infarction involving posterior limbs of internal capsule and splenium of corpus callosum consistent with severe global hypoxic-ischaemic injury.” Baby Emma was assessed by an independent Neonatal Neurologist, Dr Jeanic Cheong, who reviewed her history, current neurological status, MRI findings and EEG data, concluding that the infant had sustained a severe brain injury likely to result in either death or
severe cognitive and motor impairment.#
4 Exhibit U.
“| CB 151-3-151-7, Discharge Summary RWH.
® Ibid.
8 CB 151-6-151-7, Neonatal MRI Report.
“4 Baby Emma’s RWH Medical Records, Discharge Summary.
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15,
On 28 July 2011, following a discussion of Baby Emma’s grave condition and poor prognosis between her RWH clinicians and her parents, the decision to withdraw treatment was made.
Baby Emma died on the morning of 30 July 2011, aged four days.
Initially, Baby Emma’s death was not reported to the coroner by clinicians at the RWH who, incorrectly, did not consider the death to be a reportable death as defined in section 4 of the Coroners Act 2008.46 However, on 2 August 2011, Associate Professor Glyn Teale, Clinical Services Director of Women’s and Children’s Services at Sunshine Hospital, took a different view and reported Baby Emma’s death to the coroner, A coronial investigation including an
inquest ensued.*”
17,
This finding is based on the totality of the matcrial the product of the coronial investigation of Baby Emma’s death. That is the brief of cvidence compiled by LSC Amanda Maybury of the Police Coronial Support Unit, the statements, reports and testimony of those witnesses who testified at inquest and any documents tendered through them, and the final submissions of Counsel. All of this material, together with the inquest transcript, will remain on the coronial file.” In writing this finding, I do not purport to summarise all the material and evidence, but will refer to it only in such detail as is warranted by its forensic significance and in the
interests of narrative clarity.
The purpose of a coronial investigation of a reportable death is to ascertain, if possible, the
identity of the deccased person, the cause of death and the circumstances in which death
45 A Medical Certificate of Cause of Perinatal Death dated 30 July 2011 was completed by Dr Jennifer Sokol from the
46 46 ‘The Coroners Act 2008, like its predecessor the Coroners Act 1985, requires certain deaths to be reported to the Coroner for investigation. Apart from a jurisdictional nexus with the State of Victoria, the definition of reportable death in section 4 includes deaths that appear to have becn unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury; and, deaths that occur during or following a medical procedures where the death is or may be causally related to the medical procedure and a registered medical practitioner would not, immediately before the procedure, have reasonably expected the death [see generally s. 4(2)(a)-(b)].
47 Email dated 2 August 2011 from A/Prof Glyn Teale to the Initial Investigations Office of the Coroner’s Court of Victoria.
48 From the commencement of the Coroners Act 2008 (the Act), that is 1 November 2009, access to documents held by the Coroners Court of Victoria is governed by section 115 of the Act.
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occurred,” The cause of death refers to the medical cause of death, incorporating where possible the mode or mechanism of death. For coronial purposes, the circumstances in which death occurred refers to the context or background and surrounding circumstances, but is confined to those circumstances sufficiently proximate and causally relevant to the death, and
not merely all circumstances which might form part of a narrative culminating in death.°°
prevention tole may be advanced.
offence.*4
issue. I find, as a matter of formality, that Emma May Folwell-Kuno, born on 26 July 2011,
9 Section 67(1) of the Coroners Act 2008. All references which follow are to the provisions of this Act, unless otherwise stipulated.
50 ‘his is the effect of the authorities — see for example Harmsworth v The State Coroner [1989] VR 989; Clancy v West (Unreported 17/08/1994, Supreme Court of Victoria, Harper J.)
51 The ‘prevention’ role is now explicitly articulated in the Preamble and purposes of the Act, cf: the Coroners Act 1985 where this role was generally accepted as ‘implicit’.
2 See sections 72(1), 67(3) and 72(2) regarding reports, comments and recommendations respectively.
53 See also sections 73(1) and 72(5) which requires publication of coronial findings, comments and recommendations and responses respectively; section 72(3) and (4) which oblige the recipient of a coronial recommendation to respond within three months, specifying a statement of action which has or will be taken in relation to the recommendation.
4 Section 69(1).
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24,
died at the Royal Women’s Hospital, 20 Flemington Road, Parkville, on 30 July 2011, aged
four days.
Nor was the cause of Baby Emma’s death contentious. On 1 August 2011, a RWH’s Pathologist, Dr Gayanie Ratnayake, reviewed Baby Emma’s peri-natal history and post-natal clinical course and performed an autopsy on her body with her parents’ consent.°° Dr Ratanayake also examined the placenta and found evidence of chronic villitis and foetal thrombotic vasculopathy [FTV], with the features noted appearing to be ‘at least two weeks or
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probably older’.
Dr Ratnayake opined that chronic villitis and FTV impaired placental function such that the foetus received insufficient blood flow and nutrients, with short and long term cffects inclusive of intrauterine foetal growth restriction [FGR], greater susceptibility to hypoxia at birth, blood clots and death.*’ The pathologist advised that chronic villitis is a non-infectious chronic inflammatory condition, while FTV is a condition associated with partial or complete occlusion of foetal vessels in the placenta which can result in embolus and thrombosis in foetal blood vessels. Dr Ratnayake observed that FTV has many potential causcs including
maternal or foetal coagulation disorders, infections and maternal diabetes mellitus, however,
she was unable to determine the cause of FIV in respect of Baby Emma.
On external examination, Baby Emma was an anatomically normal female infant showing symmetrical growth restriction with weights and parameters consistent with the fifth
percentile of growth for a baby born at 40 weeks’ gestation.*
Histological sections showed large organised thrombi in the left renal hilar vessels and near
complete infarction of the left adrenal gland. These changes were characterised as visceral manifestations of FTV likely to be of up to several days’ duration given that the thrombi had
become fibrotic, a process that takes six-to-seven days to develop.
The histological sections of Baby Emma’s brain revealed extensive and diffuse hypoxic-
ischaemic damage involving the brainstem, basal ganglia, thalami, hippocampus, cerebellum
3 Exhibit U,
56 Exhibit U and Transcript page 556.
7 Transcript pages 549-550.
58 Exhibit U and Transcript page 553.
9 Exhibit U.
© Exhibit U and Transcript pages 555-556.
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27,
29,
and cerebral cortex, and which was most pronounced in the brainstem. Focal early confluent infarcts associated with gliosis and macrophage collections were seen in the pons, occipital and frontal cortex. Dr Ratanayake considcred that the changes identified seemed to be of
days’ duration rather than weeks, and possibly occurred during the perinatal period.°!
Dr Ratnayake’s analysis of other histological samples revealed features of meconium aspiration in the lungs and thymic involution, both signs of foetal distress, although she was
unable to comment on the timing of Baby Emma’s distress,
Dr Ratnayake concluded that chronic villitis and FTV in the placenta with resultant chronic
placental insufficiency led to Baby Enima’s symmetrical growth restriction and the thrombi in visceral blood vessels. These conditions rendered her more susceptible to hypoxia at birth.
Dr Ratanayake commented that the autopsy findings of hypoxic-ischemic changes to Baby Emma’s brain were not so specific as to enable her to determine whether the injury occurred before, during or immediately after birth, though the changes observed were not a ‘distant injury’. The issue of the timing of Baby Emma’s hypoxic injury is significant and will be addressed in some detail below.
At my request, Forensic Pathologist, Dr Paul Bedford, of the Victorian Institute of Forensic
Medicine [VIFM], reviewed Dr Ratnayake’s post-mortem report and provided advice about
the medical cause of Baby Emma’s death. Dr Bedford advised that it was reasonable to
attribute the cause of Baby Emma’s death to hypoxic ischaemic encephalopathy in the setting
of chronic placental insufficiency without the need for a second autopsy.®
On the basis of the evidence and advice provided by Drs Ratnayake and Bedford, I find that
the cause of Baby Emma’s death was hypoxic ischaemic encephalopathy in the setting of
chronic placental insufficiency.
61 Rxhibit U and Transcript page 552.
2 Txhibit U and Transcript pages 550-551.
8 Exhibit U.
& Exhibit U.
65 CB, pages 1-3, Mcdical Examination Report of Dr Paul Bedford dated 8 November 2011.
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In common with many other coronial investigations, the primary focus of the coronial investigation and inquest into Baby Emma’s death was on the circumstances in which she died.
Asno issues about the adequacy of her antenatal care prior to 33 weeks’ gestation were raised by Ms Folwell or on her behalf during the investigation and inquest, this period was not the focus of my investigation.
Similarly, there were no issues raised about the adequacy of the clinical management and care provided to Baby Emma at either Sunshine Hospital or RWH between her birth on 26 July 2011 and her death on 30 July 2011, and this period was not the focus of the coronial
investigation.
a, the adequacy of Ms Folwell’s antenatal care after 33 weeks’ gestation and, in particular, whether there was any opportunity for earlier intervention in relation to foetal growth restriction [FGR] and/or reports of reduced foetal movement [RFM];
b. the adequacy of the clinical management and care Ms Folwell received from the midwifery and medical staff at Sunshine Hospital from the onset of labour to Baby Emma’s delivery; and,
co. the likely timing of Baby Emma’s hypoxic-ischaemic injury.
hospital occurs when there is a medical need to do so.*? Weekly meetings betwecn midwives
6 Sce gencrally Exhibit N.
§? See gencrally the WH Antenatal Clinic Guidelines (Exhibit N) and Exhibits E, F, OQ and V. In the absence of particular concerns, the MGP anticipates about nine antenatal appointments over the course of a pregnancy, with consultations with a midwife occurring every six-to-eight weeks to 24 weeks’ gestation, monthly until 34 weeks’ gestation, fortnightly to term and weckly thereafter. A morphology ultrasound is ordinarily scheduled around 20 wecks’ gestation. Additional ultrasound investigations and other tests are scheduled by the midwife when these are clinically indicated by the presence of pre-existing or emergent risk factors or other concerns. See generally Exhibits P and N. .
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and the MGP practice manager facilitate caseload review and provide an opportunity to
‘workshop’ any clinical or logistical issues.
movements.”
decision-making in their role as the primary carers for pregnant women, including decisions
68 Transcript 367. I note that after almost a three-year investigation, the first mention of weekly MGP meetings occurred on day three of the inquest,
6 Exhibit N.
7 Exhibits N and P, ”
® According to the WH Antenatal Clinic Guidelines (Exhibit N), auscultation of the foetal heart offers no known clinical benefit to midwives and doctors, but is considered of psychological benefit to mothers, Nonetheless, it appears (hat baby Emma’s heart rate was recorded at each antenatal appointment (see CB pages 73-92, Ms Folwell’s Victorian Maternity Record [VMR]),
® Fundal height measurement [FIM] is a measure of the size of the uterus used to indirectly assess foetal growth and development during pregnancy. Fundal height is measured from the top of the mother’s uterus to the top of the mother’s pubic symphysis (junction of the left and right pubic bones). A tape measure may be used to measure fundal height or the cxaminer may use his/her fingerbreadths and knowledge of where to expect the fundal height to be at various weeks’ gestation in relation to the woman’s pubic symphysis, umbilicus or xyphoid process (lower tip of the sternum). FHM roughly corresponds to gestational age in weeks between 16 and 36 weeks’ gestation; regression of fundal height may be observed after 37 weeks’ gestation. FHM is subject to an inherent degree of inaccuracy due to its reliance on the examiner’s ability to correctly identify the top of the fundus (intra-observer error) and inaccuracy duc to differences in observations made by more than one examiner (inter-observer error). Maternal body type may also impede the accuracy of FHM.
73 Foetal movements are a sign of foetal wellbeing and may be detected by a primagravida (a woman pregnant for the first time) from around 20 weeks’ gestation and by a multigravida woman as early as 16 weeks’ gestation. Each woman’s expcricnce of foetal movements is unique. Foetal movements may be detected on palpation of the abdomen by clinicians, Pregnant women will be asked to monitor foetal movements (or patterns of movements) between antenatal visits and are/should be advised to report any reduction in foetal activity and discuss any concerns about foetal movements with their clinician.
4 Midwifery Guidclines (appended to Exhibit F). After Baby Emma’s death, statewide guidelines concerning the management of obese pregnant women were published, see Exhibit I, Maternity and Newborn Clinical Network Statewide Clinical Guidcline ~ Care of the Obese Pregnant Woman and Weight Management in Pregnancy, August
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about when a woman in their care may need medical attention during pregnancy, labour, birth
or in the post-natal period.
and actions taken in response to them are clearly documented in medical records.®?
2011 required ‘further assessment by an experienced midwife and referral for a growth
3 WH Antenatal Clinic Guide (Exhibit N).
76 T note that the guidelines contain a disclaimer stipulating that they are not intended to be prescriptive.
7 CB page 57-19, Midwifery Guidelines, page 14.
78 CB page 57-19, Midwifery Guidclines, pages 19-28. Variances from normal encompass specified pre-existing inedical conditions or gynaccological disorders of the pregnant woman, previous complicated/adverse obstetric history (including grand multiparity), indications arising or discovered during pregnancy affecting the pregnant woman or the foetus (including ‘sizc/date discrcpancy’), indications identified labour and birth (including meconium stained liquor and ‘confirmed’ non-reassuring foctal heart patterns) and post-partum complications affecting either the mother or infant.
7 Category A level of consultation and referral is to discuss the situation with a colleague — midwife and/or with a medical colleague or other health care provider; CB page 57-19, Midwifery Guidelines pages 14 and 17.
8° Category B level of consultation and referral is to consult with a medical or other health care provider, CB page 5720, Midwifery Guidelines pages 15 and 17.
5! Category C level of consultation and referral is to refer a woman or her infant to secondary care (responsibility for maternity rests with a medical practitioner) or tertiary care (responsibility for maternity care rest with a team of health care providers in a specialised hospital); CB page 57-21, Midwifery Guidelines pages 16 and 17.
®2 CB page 57-19, Midwifery Guidclincs, page 14.
3 CB page 57-29, Midwifery Guidelines, page 24.
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ultrasound scan if required’ when a size/date discrepancy of 2cm is detected.** The
significance of a size/date discrepancy is that it may indicate FGR.
delivery based on LNMP and the January 2011 ultrasound performed at her GP’s request.*°
discussed in the MGP’s regular meetings.
(contemporaneous) record of what occurred.
84 WH Antenatal Clinic Guide (Exhibit N).
85 Transcript pages 21 and 33.
86 CB pages 73-76, Ms Folwell’s VMR.
87 Transcript pages 339, 340, 342 (Budge) and 567 (Currie).
88 ‘l'ranscript page 343 (Budge) and 567 (Curric).
89 'l'ranscript page 344 (Budge); this approach to note-keeping appears to be endorsed by Ms Currie at page 566 Compare this to Ms Currie’s contrary account, at ‘lranscript page 652, when questioned by me, namely, that her usual practice is to make a note to reflect a discussion about a maternal report of RFM even if she had reached the conclusion that there was no reason for concern or further action/investigation.
% Transcript page 340 (Budge). I note that Ms Currie made informal notes following Ms Folwell’s labour and Baby Emma’s delivery (about those events), the existence of which emerged while she was giving evidence at inquest (Transcript page 569) and the notes themselves were ultimately tendered as Exhibit W.
3} CB pages 63-73, Ms Folwell’s Western Health Medical Records for the antenatal period.
% Transcript pages 339 (Budge) and 568-589 (Currie).
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°55 of the notes in Ms
patient’s care could be anticipated.”! She commented on the ‘paucity Folwell’s VMR generally and characterised them as lacking in useful information and
providing little indication about what discussions had actually taken place.”
44, Prof McDonald noted that there was no evidence in medical records that any consultation with a doctor had occurred in relation to Ms Folwell’s modcrate obcsity and grand multiparity as recommended in the Midwifery Guidelines.?’ She considered that Ms Folwell’s increased risk of gestational diabetes due to her high BMI was an additional indication for consultation/comprehensive screening by Glucose Tolerance Test [GTT], though one outside
the guidelines.”
midwife should not continue to provide Ms Folwell primary antenatal care.”? However, given
the accumulation of conditions, a discussion with Ms Folwell, a medical practitioner and any _
other relevant members of the maternity services team, and evidence of a plan of pregnancy care, should have been documented as part of the decision-making framework." Prof McDonald noted that there was no evidence that any such discussions occurred or that Ms
Folwell’s suitability for midwife care was considercd.!°!
33 "l'ranscript pages 324 and 325.
54 Transcript pages 326
95 Exhibit L.
56 l'ranscript page 269.
97 Exhibit L and Transcript page 276.
8 Pxhibit L, Prof McDonald was critical of the midwives’ failure to follow-up on Ms Folwell missing a GTT after aprecing to a referral for this test. The lack of follow-up was explained by Ms Currie as arising from her assessment that Ms Folwell’s risk of gestational diabetes was ‘low’ (a view Prof McDonald disputed: only a normal BMI would have indicated Ms Folwell was at low risk of gestational diabetes). Prof McDonald testified that Ms Folwell’s weight/high BMI warranted closer observation throughout her antenatal care, including pursuit of a GT'l’. She advocated weight monitoring during pregnancy for women with increased BMI, to monitor the health of the mother ('ranscript page 295).
There was some disagreement, particularly between Prof McDonald and A/Prof T’cale about the value of monitoring the mother’s weight during pregnancy as ‘onc factor in many to be considered in predicting FGR’ (Transcript pages 291292 [McDonald]; compare with page 197 [Teale]).
°° Txhibit L and Transcript page 276.
100 Exhibit L and ‘I'ranscript pages 272-273.
{01 Exhibit L.
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7104 and, as she sought to come to terms with the tragedy of Baby Emma’s death, quite
“vent understandably, had researched hypoxic-ischaemic encephalopathy'” and discussed the
relationship between RFM and FGR with her family doctor.!%
47, Ms Folwell testified that shc had no concerns about the pregnancy before 34 weeks’ gestation.’ However, after that, during antenatal appointments in June and July 2011,1"8 she told her midwives of her concerns that Baby Emma felt ‘smaller’!™ than other babies she had carried and that she was not as active, not a ‘thrasher like the boys’.!!" Ms Folwell felt she ‘wasn’t heard’!!! by the midwives when she raised these concerns.'!?
she was told that the results of the June 2011 ultrasound were good.'!3 Ms Folwell said she
12 Ms Folwell wrote to the Court on three occasions: 7 October 2011 (Exhibit A), 28 June 2012 (Exhibit B) and [date received] 16 August 2012 (Exhibit C). The first lettcr related to her concerns that Baby Emma had not been delivered by Caesarean section. The two subsequent lcttcrs raise concerns about antenatal care and, specifically, concerns reportedly raised by Ms Folwell during appointments with midwives that Baby Emma was ‘small’ and RFM and a chronology of events occurring between 24 and 26 July 2011.
103 Transcript page 15.
104 Transcript page 19.
1°5 Transcript page 15; Ms Folwell researched hypoxic ischaemic encephalopathy [HIE] and something else which was not transcribed due to being inaudible on the recording of the inquest.
106 Transcript pages 15 and 61.
197 Transcript page 37.
‘08 That is, 34-39 weeks’ gestation.
10 Exhibit B and Transcript pages 17 and 37.
NO Rxhibit B and Transcript pages 63, 68 and 67.
"! Transcript page 17.
112 Ms Folwell said that had faith in the midwives (Transcript page 18) but also that she did not feel that she could have consulted another midwife or medical practitioner if she was not satisfied that her concerns had been considered (Transcript page 17).
'8 Transcript pages 17 and 45-46.
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| | | | | | | |
was somewhat reassured! '4 by the midwives’ attribution of Baby Emma’s different ot gentler movements to her sex!!> but continued to report after 34 weeks’ gestation that Baby Emma was ‘not as active’ as her brothers had been.!!© When it was put to her at inquest that her recollection of events — in particular her report of RFM after 34 weeks’ gestation — had been influenced by information she had learned from her GP, the coronial brief and independent research conducted after Baby Emma’s death, Ms Folwell said she did not know how to
respond to the question.!!7
49, For their part, both RNM Currie!!® and RNM Budge!” denied that Ms Folwell had reported RFM prior to 26 July 2011 or that Baby Emma felt small. To corroborate their accounts they pointed to the absence of any relevant note in the VMR.!”° The midwives testified that asking
a pregnant woman about foctal movements is fundamental and a standard component of
antenatal appointments”! and, in common with other witnesses,'”* confirmed the significance
of the pregnant woman’s perception of them’ to antenatal and perinatal management. They
indicated that their usual practice, an approach endorsed by the other clinical!** and expert
"4 Compare Transcript page 23 (Ms Folwell was reassured) and page 63 (she did not believe the different movements she perceived were attributable to Baby Emma’s sex). .
'l5 Ms Folwell testified that both Ms Currie (Transcript page 23) and Ms Budge (Transcript page 69) attributed concerns about Baby Emma’s size/movement to her sex. The midwives denied the comments.
‘16 Transcript page 67. It is implicit in Ms Folwell’s evidence that she perceived Baby Emma’s movements to be no different to her other babies’ prior to 34 weeks’ gestation; thereafter, she perceived thal Baby Emma was not as active as she (or they) had been.
‘7 Transcript pages 61-62 but see generally Transcript pages 58-63.
118 Transcript pages 565 and 625, "9 Transcript page 339.
20 Transcript pages 566 (Currie) and 339 (Budge). I note that a document entitled ‘Woman’s & Children’s Investigation Report: Folwell UR**’, was disclosed to the parties and to the Court but not tendered as evidence, which was authored by Susan Gannon, WII’s Divisional Director, Women’s & Children’s Services, and dated August 2011.
The document was reportedly prepared at A/Prof Teale’s request to investigate the management of Baby Emma’s birth and make any recommendations to improve the midwives’ clinical practice. Little was known of the status of the document or how the investigation was conducted. Ms Gannon was not called to give evidence. Of relevance here are the comments attributed to the various clinicians involved in the management of Ms Folwell’s labour which appear to contradict accounts provided later in sworn statements. I note that witnesses to whom contradictory accounts were put at inquest denied that they had made the early inconsistent statements attributed to them.
21 Transcript pages 567 (Curric) and 338 (Budge).
12 Transcript pages 105-106 (Kay), 127-129 (Teale), 262 (Jacobs), 509 (Irshad), 206, 210-211, 232-233 (Tippett), 285, 286, 307, (McDonald), 471-472 (Hyett), 423-425, 443, 451 (While).
123 The importance of the pregnant woman’s perception of foctal movements is also emphasised in the WH Antenatal Clinic Guide (Exhibit N).
[4 Transcript pages 105-106 (Kay), 127-129 (Teale), and 262 (Jacobs).
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witnesses,!”° was that if RFM is reported by a pregnant woman, it would raise a ‘flag’ for the
midwife and prompt further discussion and/or investigation through clinical examination
and/or referral for CTG, which would, in tum, lead to obstetric review. |
will return later.
25 Transcript pages 206, 210-211, 232-233 (Tippett), 278-279, 285-286, 307, (McDonald), 471-472 (Hyett), 423-425, 443, 451 (White).
226 Transcript pages 565-567 (Currie) and 339 (Budge).
'27 Transcript pages 652 (Currie) and 339 (Budge).
28 Transcript pages 566 [o//f page 652] (Currie) and 344-346 (Budge).
29 Ms Folwell’s VMR.
'80 Transcript page 585,
5! Transcript page 563.
12 Transcript page 562 and Exhibit V. Ms Currie also referred Ms Folwell for a GTT as recommended by guidelines for women with a high BML.
133 See CB 67-72 (May and Junc 2011 ultrasounds) and CB 41-44 (Independent expert report of Dr Amanda Sampson, Radiologist).
4 Exhibit V, Transcript page 374 and M Folwell’s VMR.
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consultation or ultrasound investigation of possible FGR.
"137 and so did not consider there to be any
discrepancy of two centimetres ‘or greater indication for medical or other review.'* Moreover, despite there being only a FHM increase of one centimetre in the three weeks’ between 4 and 25 July 2011, RNM Currie insisted that she had not been concerned that Baby Emma’s growth had plateaued because ‘when [she] performed the abdominal palpation [she] felt that there was growth in that baby’ °? and so did
not consider other options for monitoring her growth.'“°
limited sensitivity and accuracy.*’ The accuracy of cach is further compromised by maternal
obesity. !**
55 Ms Folwell’s VMR.
138 Ms Folwell’s VMR.
‘37 Transcript page 625. Ms Budge considered that a FHM discrepancy of 2 or 3 cm would be a variance from normal (Transcript page 372).
‘388 Transcript page 625.
39 Transcript pages 567 and 624.
40 ‘Transcript page 568.
14! The risk of adverse outcome or death of the foetus from FGR also increases as the pregnancy advances and so delivery before 40 weeks’ gestation is recommended.
12 Transcript page 125 (Tcalc). A/Prof ‘Teale produced (but did not tender) the Victorian Department of Health’s ‘Victorian maternity scrvices performance indicators — Complete set for 2010-11 and 2011-12’, published in 2014, from which the statistic is derived [available at www.health.vic.gov.au/maternitycare]. Other experts agreed with the estimated rate at which severe 'GR is ‘missed’ clinically.
143 See generally the comments made by A/Prof Teale, Dr Tippett and Profs Ilyett and McDonald in their oral evidence.
\4 Sec for instance Transcript page 471 (Hyett).
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Measurements of fundal height and ultrasound findings provide a snapshot of foetal development at a particular juncture and, of course, do not preclude disturbance of the developmental trajectory at a later point.'* Overall, the accuracy of ultrasound measurements and FHM performed by an experienced clinician is estimated to be about 70 per cent.!° Notably, when ultrasound measurements are inaccurate, for instance foetal weight estimated from ultrasound, they can be inaccurate by as much as ‘plus or minus 20 per cent’.!7 The
limitations of these techniques are often poorly appreciated by midwives and medical staff. '4*
RNM Currie testified that there was nothing in Ms Folwell’s clinical antenatal course to justify referral to an obstetrician for review.!"? A/Prof Tcalc and Dr Bernadctte White, the Epworth Freemasons Medical Centre Consultant Obstetrician and Gynaecologist retained by WH to provide an cxpert opinion about Ms Folwell’s obstetric management, endorsed that
vicw.!°° It was, however, a minority view among the experts who testified at inquest.
The weight of the expert evidence was that whilc Ms Folwcll’s antenatal management ‘wasn’t terrible,’ it was ‘suboptimal’ and that an opportunity to intervene was missed.'! Prof McDonald,'? Dr Tippett,!? the Court’s independent Obstetric expert and Head of Maternal Foetal Medicine at Monash Health, and Prof Hyett,!%* an Obstetrician and Head of High Risk Obstetrics at the Royal Prince Alfred Hospital retained by Baby Emma’s family to provide an cxpert opinion, each testified that obstetric review would have been appropriate, particularly in response to static FHM. Profs McDonald and Hyett explicitly disagreed with A/Prof
Teale’s view that it was only possible to conclude that the clinical evidence potentially
{45 A number of the medical witnesses weighed the ultility of serial measurements and ultrasounds (see generally the evidence of A/Prof Teale, Dr Tippett and Dr [yett). Dr Hyett was a notable proponent of taking a ‘longitudinal’ view of the clinical picture rather than a cross-sectional one (Transcript page 494),
46 Transcript page 234. Dr Tippett provided an illuminating explanation of the features examined by ultrasound, how they are useful clinically and the limitations of the technology to detect FGR (Transcript page 206).
47 Transcript page 225.
148 Transcript page 234. A number of experts referred to the ‘false reassurance’ provided by, particularly, ultrasound findings. Dr Tippett and Prof McDonald notes clinicians’ ‘over-contidence’ in their tools generally. Dr Teale characterised the June 2011 ultrasound as ‘misleading’ (Transcript page 150).
49 Transcript page 620.
150 See generally Exhibit F and Transcript pages 110-202 (Tcale) and Q and Transcript pages 421-459.
15! Transcript page 229 (Tippett).
182 Bxhibit I. and Transcript pages 276-277,
'S3 Transcript pages 218 and 230,
Transcript page 464,
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indicated FGR with the benefit of hindsight.'° The experts agreed that Ms Folwell’s pregnancy appeared to be progressing well to about 34 weeks’ gestation.°° However, by the 38-weck appointment on 18 July 2011, notwithstanding the limitations of FHM and the ; reassuring June 2011 ultrasound, Prof McDonald, Dr Tippett and Prof Hyett opined. that FHM
demonstrated a variance from normal indicating a need for obstetric review. !°7
138 observed that while guidelines are
centimetres stipulated in the Midwifery Guidelines, important they should not supplant clinical judgment’ and, notwithstanding a number of potentially benign explanations! for little difference in growth over a three week period, she
would have been concerned enough to seek a medical opinion.'®!
162 adding that FGR is a relatively rare abnormality that is
normality’ is not helpful.!©
had identified and documented that there ‘could be a problem, but then didn’t translate that
155 Transcript pages 296 (McDonald) and 496, 498-499 (Hyett).
156 Transcript pages 310-312 (McDonald) and 480 (Hyett) and Exhibit J.
15? Transcript page 318 (McDonald), 205 (Tippett) and 464 and 506 (Hyett). Dr Tippett’s opinion appears somewhat more equivocal by the end of her evidence. Unfortunately, she does not completely answer a question which would clarify whether, in the absence of a report of RFM by Ms Folwell, there was sufficient clinical evidence (ie FIIM ‘alone’) to warrant obstetric review (sce 218, 229 and 230).
'58 Transcript page 314.
159 Transcript page 315. I note that Ms Currie used ‘clinical judgement’ to explain her non-compliance with the WH Antenatal Clinical Guideline and not seek review for a 2cm size/date discrepancy (Transcript page 568).
'60 Such as the foctus’ head descending into the pelvis, reduction in amniotic fluid in the latter stages of pregnancy and inter-obscrver error (['ranscript pages 317-318).
‘61 Transcript page 318.
1® Transcript page 497, ‘Guidelines provide guidance to clinicians, clinicians examine patients’ (Hyctt).
16 Transcript page 498-499,
164 Transcript page 471.
‘55 Transcript page 463.
16¢ Exhibit J.
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into action’.!©’ I note that none of the experts went so far as to suggest unequivocally that the
absence of obstetric review was unreasonable, '*
CTG monitoring and/or induction of labour pre-term.!”!
Ms Folwell’s last antenatal appointment — 25 July 2011
Ms Folwell said she had felt better on 25 July 2011. When cross-examined, she reiterated that she had reported her own ill-health and RFM but that the midwife did not write this in her
63, RNM Currie denied that Ms Folwell reported feeling unwell on Sunday, 24 July 2011 when they met the following day.!% She testified that on 25 July 2011 Ms Folwell had been
‘8? Transcript page 234.
‘68 See for instance, Prof Hyett’s comments at Transcript page 481. I note that all of the experts tended to couch their opinions in terms of ‘I would have done ...’ rather than the less equivocal, ‘In my opinion best practice requires ...’, Not all experts were asked the same questions in the same terms. The multiplicity of variables ‘put’ to the experts in cross-examination often confounded the delivery of a clear and unequivocal answer to some questions,
16 Exhibit Q.
1 Transcript pages 231 (Lippett), 506 and 463 (Ilyett), and Exhibits J and S.
171 ‘Transcript pages 231 (Tippett), 506 and 463 (Hyett).
1? Transcript pages 75-76,
' Thid.
'74 Transcript page 34.
'75 "Transcript page 570.
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excited about the birth and was looking forward to meeting Baby Emma.'”® She had made a corresponding note, ‘All well, baby active. Waiting patiently,’ in the VMR.!”? RNM Currie stated that Ms Folwell first told her that she had been unwell, in bed, and that the baby had been less active when they spoke by telephone on Tuesday, 26 July 2011.'8 At that point, though ‘surprised’ to hear Ms Folwell had been unwell on the Sunday, she had not queried her apparently inconsistent report during the intervening antenatal appointment, advising instead
that Ms Folwell attend the hospital for CTG monitoring!”
Prof McDonald commented. on the apparent incongruity of the accounts of Ms Folwell and RNM Currie of the content of their last antenatal appointment. She observed that it was counter-intuitive to believe that RNM Cutrie would have not discussed and noted a report of maternal ill-health and RFM if one was made.!®° Similarly, she found it difficult to believe that Ms Folwell, having been unwell and bed-bound, would have reported only that all was
well the following day. The accounts are, unfortunately, irreconcilable.
At 3.38pm on Tuesday 26 July 2011, Ms Folwell called RNM Currie'®’ to report that ‘things
weren’t right’.!®* She had experienced pains that did not feel like normal labour pains since about 1 lam and Baby Emma’s movements had slowed. At the time of the call, she was grocery shopping and testified that RNM Currie advised her to go home and relax, have a cold
drink to stimulate foetal movement, and call back in an hour.'** Ms Folwell telephoned RNM
"% Transcript page 631.
7 Ms
Folwell’s VMR.
'8 Transcript page 631.
"9 Transcript page 631.
180 Transcript pages 286-287.
181 Ms Folwell produced one page of a mobile telephone bill for 22-29 July2011 on which she had highlighted calls made to Ms Currie, which was appended to Exhibit C. A call is logged to Ms Currie’s mobile telephone number at 3.38pm on 26 July 2011. :
182 Exl
183 Df
hibit B.
hibit B and Transcript pages 29-30 and 79.
184 Transcript pages 29-30 and 79,
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| | | | | |
Currie again at 4.32pm on 26 July 2011!* and reported that there had been no improvement in
her condition."®° She was told to go to Sunshine Hospital.!®”
At inquest, RNM Currie testified that she only recalled one telephone call from Ms Folwell on 26 July 2011.'88 Her account of it is different to that of Ms Folwell. She confirmed that Ms Folwell reported RFM, denied advising Ms Folwell to have a cold drink and call back in an hour and testified that she asked her to come in for CTG review.'*” RNM Currie called the
assessment centre of the birthing unit to advise staff to expect Ms Folwell.!”°
According to ANUM Kay, in 2011 caseload midwives were ‘quite independent’ in their management of their patients while in the birthing unit and would not necessarily ‘tell you absolutely everything’ about their patient.!*' She observed that training delivered since that time had improved collaboration between midwives, the ANUM and obstetric/medical staff.!°? In the absence of complications, midwives may be the only clinicians present during labour or delivery.! However, midwives would consult the ANUM or escalate obstetric concerns to the Consultant Obstetrician or Obstetric Registrar on duty if necessary. Once
consulted, medical staff would expect to be involved in management of a labour to some
degree thereafter!™* and in such cases clinical decision-making is led by the Consultant or
Registrar.!°° Similarly, if medical staff have asked for an update from a midwife within a
particular period and the update is delayed, the doctor would follow-up personally.!°° In
'85 Appendix to Exhibit C. A call is logged from Ms Folwell to Ms Currie’s mobile telephone number at 4,32pm on 26 July 2011
186 Exhibit B.
187 Transcript page 30. Ms Folwell stated that she told Ms Currie that she was ‘coming in’ whereas Ms Curric testified that she advised Ms.Folwell to attcnd hospital for review.
‘88 Transcript page 571.
'® Transcript page 571.
199 Transcript page 572.
19! Transcript page 97.
22 Ibid. ’
183 Transcript page 521.
4 Tid.
15 Transcript page 406.
'°6 Transcript page 521.
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2011, only medical staff could authorise a Caesarean delivery'”’ and, once a decision for
surgical intervention is made, delivery would ordinarily occur within about 20 minutes.'”*
.68. At 5pm, Ms Folwell was admitted to the assessment centre by RNM Budge. She confirmed information the midwife had already been provided by RNM Currie, namely, that Baby Emma “wasn’t moving well’ and Ms Folwell ‘might be in early labour’.°? RNM Budge applied a CTG to provide continuous external monitoring of the foetus and any uterine contractions.
After a few minutes, she observed a deceleration of the FHR to 60bpm with good recovery associated with a mild contraction. Unsure whether this pattern on the CTG trace indicated that Ms Folwell was transitioning to the second stage of labour, RNM Budge consulted RNM Curric
who had just become available to take over care.*%
| | ) |
69, At about 5.10pm, RNM Currie performed a vaginal examination [VE] with Ms Folwell’s consent to assess the progress of her labour. Ms Folwell’s cervix was three centimetres dilated and effaced, with bulging membranes. The midwife estimated that Baby Emma’s head was at station -27"! and that the FHR was 140bpm. Contractions were irregular and mild and occurring
at a rate of one every 10 minutes. RNM Currie concluded that Ms Folwell’s labour was not
established and birth was not imminent.?°* The midwife noted her observations in the medical record along with the reported history of ‘tightenings’ since | lam, with some stronger
contractions 20-30 minutes apart during the day, and concern that Baby Emma’s movements
had decreased,?°3
2204 205 as
concluding that it appeared ‘abnormal’” and characterising it, retrospectively, a
‘sinusoidal pattern’.2°
197 Transcript pages 407, 641, and 89-90, 198 Transcript page 101.
1 Transcript page 369.
200 Exhibit O.
201 The ‘foetal station’ refers to the position of presenting part of the foctus in relation to the mothcr’s pelvis. 0 station refers to the foetus’ head being even with the ischial spines (the narrowest part of the pelvis). The foetus is said to be
‘engaged’ when the largest part of the head has entered the pelvis. If the presenting part lics above the ischial spincs,
the station is reported as a negative number from -] to -5,
202 Exhibit V.
203 CB 115 (reverse sidc), Ms Folwell’s WH progress notes.
204 Exhibit V.
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since Sunday’.
72, Dr Jacobs denied that RNM Currie had handed over Ms Folwell’s report of RFM.”!° The Consultant said that if she had known this history, she would have called for a Caesarean delivery straight away.7!! When Dr Jacobs’ evidencé about the handover was put to her at inquest, RNM Curric commented that it was ‘possible but very, very unlikely’*” that she had failed to handover a history of RFM becausc providing a ‘complete clinical picture’ was her
usual practice.”
205 There was some effort at inquest to determine whether anyone had used the term ‘sinusoidal’ to describe Baby Emma’s CTG trace during the labour given that the term first appears in the medical notes in a retrospective progress note made by Ms Currie on 28 July 2011. Ms Currie thought she used the term when informing the consultant about the CTG trace around 5.30pm (Transcript page 573-574); Ms Budge testified that the term was never used in her hearing on 26 July 2011 (Transcript page 350); Dr Jacobs’ evidence was that Ms Currie had not described the CTG trace as sinusoidal (Transcript page 250) and that she had ‘missed’ that it was ‘sinusoidal’ at the time (Transcript page 251); ANUM Kay did not consider the CTG trace to have a sinusoidal pattern because it improved after the artificial rupture of membranes’ (Transcript page 88).
205 Exhibit V. A ‘sinusoidal’ CTG pattern is described as a smooth, regular, wave-like pattern with a frequency of about two-five cycles per minute, a stable foetal baseline heart rate of 120-160bpm and no beat-to-beat variability, Sinusoidal CTG patterns indicate severe foetal hypoxia (among other things) and are associated with high rates of foetal morbidity and mortality,
207 Exhibit V and Transcript page 573. Originally, Ms Currie had thought that Dr Irshad was also present during this handover but at inquest, conceded the possibility that Dr Irshad was not present when she first reported the abnormal CTG trace to the obstetric team around 5.25pm (Transcript page 575).
208 Para is an abbreviation of ‘parity’ (he number of times a woman has given birth) and Gravida is an abbreviation of the term ‘gravidity’ (the number of times a woman has been pregnant).
209 Exhibit V and Transcript page 573.
210 Transcript page 242, Dr Jacobs stated that the only information handed over was that Ms Tolwell was a multiparous woman in labour, who had seven previous normal vaginal births and had been experiencing abdominal pain and increasing contractions and that she seemed anxious and distressed (Transcript page 244).
211 Transcript page 251-252.
222 Transcript page 614, 213 Transcript page 574.
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suggested by it.25
74, At about 5.25pm, Dr Jacobs attended Ms Folwell in the assessment centre. Upon reviewing
1°!6 noting in particular, that at
the CTG trace she formed the opinion that it was ‘abnorma about 5.02pm and again at 5.26pm there were decelerations of the FHR to 50bpm and, generally, that there was poor beat-to-beat variability!’ She considered the CTG trace to be concerning but ‘not terminal’.?'* At inquest, Dr Jacobs stated that ‘on reflection,’ the first 30
minutes of the CTG trace was ‘sinusoidal’, but she had ‘missed it’ at the time.?!
scalp electrode [FSE]> monitoring to ‘confirm this was a poor trace’.226 If the CTG trace
214 Transcript page 410 and 420. Ms Kay’s statement (Exhibit E) suggests that Ms Currie’s initial escalation of concerns about the CTG trace was to the ANUM who, in turn, escalated the matter to the Consultant. I note that this is the only account presenting this chronology.
25 Transcript page 102.
216 Exhibit K and Transcript page 238.
27 Transeript page 239,
218 Transcript page 240,
219 Transcript page 251.
29 Transcript page 238.
221 Transcript page 243. Dr Jacobs conceded that she should have taken a history from Ms Folwell.
222 Dr Jacobs conceded at inquest that she ought to have examined Ms Folwell herself — though at what point (initially or otherwise) is unclear (Transcript page 263). A/Prof Tealc voluntecrs that the Consultant’s failure to examine the patient hersclf is ‘one of the difficulties’ with Ms Folwell’s management (Transcript page 179).
223 See Ms Folwell’s WH medical record.
4 Transcript page 241, also Exhibits E, K, O and V.
225 A foetal scalp clectrode is placed directly on the foetal scalp through the cervix. It detects actual beat-to-beat electrical signals of the foetal heart to enable it to be monitored directly (as CTG monitoring of the FHR is sometimes confounded by maternal pulse),
226 Exhibit K and Transcript page 240,
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‘continued to be abnormal’, her plan was for a Caesarean delivery,?”’ and in any event, did not anticipate that the decision’as to mode of birth would be made more than 30 minutes after her first review at 5.30pm.”8 Dr Jacobs asked that Ms Folwell bc transferred to the birthing unit and she and the ANUM went to the unit ahead of them.
RNM Currie reportedly queried Dr Jacobs’ decision to proceed with an ARM and was told.
that its purpose was to obtain ‘more information’.?”” Although checking the colour of the liquor was not unreasonable in her opinion, she considered it a ‘waste of time’.“” RNM Currie thought that Baby Emma needed to be born ‘sooner rather than later,’ and that a Caesarean section [C-section] delivery was most likely given that Ms Folwell was only 3cm dilated and ‘not really in labour’.?*! For her part, Dr Jacobs perceived ‘a little bit of obstructive behaviour’ from the midwives directed at her for ‘interfering in clinical
management’.?? It made her fecl unwelcome and her job more difficult.??
In the birthing unit, ANUM Kay commenced the paperwork for a C-section delivery in case it was needed.44 Dr Jacobs recalled waiting about 10 minutes in Room 4 for Ms Folwell to arrive, but she did not. She was informed via ANUM Kay that Ms Folwell was still in the assessment centre and the CTG transducers had been removed as she was using the toilet.
Before Ms Folwell arrived in Room 4, Dr Jacobs was summoned to attend another patient.?**
As she was called away, Dr Jacobs instructed the Obstetric Registrar, Dr Ghazala Irshad, to ‘keep a close eye on’ Ms Folwell because she, Dr Jacobs, was concerned about the CTG trace
and if ‘progress was not satisfactory, or if the tracc continued to be bad,’ she should cxpedite
227 Axhibit K,
228 Transcript page 240.
29 Transcript page 576.
230 Transcript page 576,
33! Transcript page 575.
232 Transcript page 241,
233 Transcript page 242.
24 Exhibit E and Ms Folwell’s WH medical record,
235 Exhibit K. I note Dr Jacobs’ evidence at inquest was that the ‘main reason’ she left was the ‘unfriendly environment’ (Transcript pages 263-264).
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delivery with a C-section.” Dr Irshad’s account is significantly different as will be seen
below,
with saline,”? and that there was no Syntocinon’? administered at that time.?“* Her account is
corroborated by Ms Folwell’s medications chart.?45
80, At about 5.50pm, RNM Currie performed a second VE with Ms Folwell’s consent. She noted
that the cervix remained three centimetres dilated and effaced, Baby Emma’s head was 1-2cm
above the ischial spines and her heart rate was 142bpm.”*° The midwife performed an ARM, noting the presence of old, thick meconium” in the draining amniotic fluid. RNM Currie immediately went to the midwives’ station and reported the presence of meconium in the
liquor and a lack of progress of the labour to Dr Jacobs,”* and, she believes, Dr Irshad.*””
236 Transcript page 241, 1 ulso note Ms Kay’s recollection that Dr Jacobs directed her and Dr Irshad monitor the CTG trace, though there is no indication as to what time this occurred (Exhibit E), Ms Kay said in her statement that Dr Irshad to re-examine Ms Fol well aftcr 20 minutes and that she let to see other patients as there were two experienced midwives with Ms Folwell (Exhibit E). ‘lhe last contemporaneous note made by Ms Kay in Ms Folwell’s medical record is a note timed at 1835 of permission for a VE to be performed
237 Exhibit V.
238 | ranscript pages 606-607.
239 A Hartmann’s solution is used to replace mineral salts and body fluids.
240 ‘Transcript page 92.
4 Transcript page 414.
2 Transcript page 419.
243 Syntocinon contains oxytocin which is a human peptide hormone and neuropeptide that is used to facilitate childbirth and may be administered (at different rates) to induce labour or control post-partum bleeding.
244 'Transcript pape 415.
45 CB 121, Ms Folwell’s WH Medication Charts.
246 CB 116, Ms Folwell’s WH Progress notes.
247 Meconium is the earliest stool of a mammalian infant. Its presence in ammiotic fluid is a sign of foetal distress.
248 Transcript page 634.
249 Exhibit V and Transcript page 635.
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RNM Currie recalled no specific instructions at that juncture, beyond being asked to apply a
Dx Irshad testified that she had been in the Emergency Department until about 6pm and so disagreed with RNM Currie’s recollection that she was present in the maternity ward when the presence of meconium-stained liquor was handed over to obstetric staff2°! By her account then, it was around 6pm that Dr Jacobs first gave her instructions about Ms Folwell’s - management.%? The Consultant informed her that Ms Folwell was a ‘multigravida with meconium-stained liquor’ and that there were ‘some decelerations’ on the CTG trace.*?_ Dr Irshad stated that the ARM had beon performed, the Consultant was aware of what it revealed and had already determined how to proceed prior to her involvement in the case.?*4 Her instructions were to ‘keep an eye on Ms Folwell’ and, if she had any concerns about the CTG trace, to call off the labour and proceed with a Cacsarcan delivery.” Dr Irshad testified that she was only ‘actively involved’ in Ms Folwell’s management after 6.40pm when she
performed a VE.?%
Dr Jacobs’ evidence was that Dr Irshad telephoned her to inform her that meconium was present following the ARM.” Although she did not say when this occurred, the Consultant stated that the Registrar also reported that the CTG trace had improved when the FSE was attached.*58 Dr Jacobs observed that meconium and an abnormal CTG is an indication for Csection delivery, but not meconium alone.’ She remained concerned and told the Registrar
that if there was a ‘delay’ in progress of labour, C-section delivery should still be
230 Ex]
hibit V.
251 Transcript page 533.
252 Transcript pages 520, 526 and 530,
253 Exl
hibit T.
254 Transcript pages 514 and 532-533.
255 Ex
hibit T.
256 Tyanscript page 533.
257 Exl
258 Ex
hibit K,
hibit K and Transcript page 244. In terms of timing, it may be possible to assume that the communication
occurred after 6.20pm when the first FSE was applied, and perhaps closer to 6.40pm, when Dr Irshad first examined Ms Folwell and reviewed the CTG trace.
259 By’
ibit K.
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85,
considered.”°° She directed that Dr Irshad perform a repeat VE in 20 minutes to see how labour was progressing.”*! I note Dr Jacobs’ evidence that she had faith in Dr Irshad and the
ANUM and, at the time, had been reassured by their assessment of the CTG trace.2® With
hindsight, the Consultant conceded that she ought to have ‘stayed to make the decision???
and reviewed the CTG trace again.”
herself, should have performed a VE hersel
These conflicting accounts give risc to the possibility that there was a decision-making
vacuum at a critical stage of Ms Folwell’s clinical management.?°°
At around 6pm, and also at about 6.05pm, 6.10pm and 6.15pm, the CTG trace demonstrates a loss of contact such that there is a gap in FHR monitoring.2” At 6.10pm, Ms Folwell is noted to be toileting.” At 6.20pm, RNM Currie applicd the first FSE.?®
At about 6.30pm, the CTG trace showed a baseline FHR of 135-140bpm, with decreased beatto-beat variability and variable decelerations. Ms Folwell’s contractions continued to be mild and were occurring at a frequency of one every 10 minutes. RNM Currie formed the view that the CTG trace remained abnormal and telephoned Dr Irshad to request review.?” Shortly thereafter, the midwife noticed that the FSE appeared to have fallen off.
At 6.40pm, Dr Irshad attended to examine Ms Folwell.?”! The Registrar performed a VE with
consent, noting that the cervix was dilated to 5-6cm and was 90 per cent effaced and that Baby
260 Transcript page 245, I note Dr Jacobs’ evidence (which is somewhat at odds with the previous transcript reference) that she had faith in Dr Irshad and the ANUM and, at the time, had been reassured by their assessment of the CTG (Transcript page 252).
261 Transcript page 246,
Transcript page 252.
263 Transcript page 252.
26 Transcript page 263.
Transcript pages 256 and 246.
266 On any view of the evidence, the known circumstances were that Ms Folwell had been in the maternity ward for about an hour, there had been a period of abnormal CTG trace, an ARM reveuling meconium-stained liquor and two VF’s demonstrating poor progress of labour and that birth was not imminent.
267 Bxhibit R.
268 Fxhibit R.
269 Exhibit R.
2 Exhibit V. Dr Irshad disputes this account.
27 Transcript page 510. Dr Irshad stated that she was responding to Dr Jacobs’ instructions to ‘keep an eye on’ Ms Folwell rather than either of the two summonses Ms Currie claims to have made around 6.30pm.
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Emma’s head remained at station -1 or -2.2”” The membranes were absent and a very small
amount of meconium-stained liquor was draining.?”
continued to demonstrate reduced variability of the foetal heartbeat, Dr Irshad considered that
it was ‘comparatively better’ than the trace reviewed carlict by Dr Jacobs.2” She formed the
view that there was no indication to proceed to Caesarean delivery as Ms Folwell’s labour was progressing ‘rapidly’.2” She advised RNM Currie to’continue to monitor the CTG trace and
to call her if she was concerned.”
CTG trace.”®°
had finished using the toilet and asked her to leave the room." Dr Irshad testified to feeling
22 CB 116, Ms Folwell’s WH Progress notes.
2% Ibid.
2% Exhibit R.
275 Exhibit T.
2% Thid.
277 Exhibit R and CB 116, Ms Folwell’s WH Progress notes, 278 Exhibit V.
9 Thid.
289 Exhibit V. Dr Irshad testified (Transcript page 525) that she was summoned to attend by ANUM Ms Kay and so it may be that the request was relayed.
28! Exhibit R and CB 116, Ms Folwell’s WH Progress notes.
282 Exhibit T.
283 Exhibit and ‘Transcript page 514.
284 Transcript page 515.
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‘frustrated’ and ‘blocked’ by the midwife, but had not considered it appropriate ‘in that
environment’ to order people (the midwife) around.
they were of moderate strength.*8 Baby Emma’s baseline heart rate was about 130bpm.?®
summoned to attend the birth.2!
immediately.??
Expert Midwifery and Obstetric Evidence
paticrn sufficiently ‘regular’ to be characterised as sinusoidal and noted a ‘couple of little
285 Transcript page 515.
286 CB 116, Ms Folwell’s WH Progress notes.
287 CB 116, Ms Folwell’s WH Progress notes. Ms Currie’s contemporaneous note times the FSE falling off at about 7.19pm while in a retrospective note, Dr Irshad times her notification of the second detached FSE at 7.10pm.
288 CB 116, Ms Folwell’s WH Progress notcs.
289 CB 116, Ms Folwell’s WH Progress notes.
290 Thid.
291 Hxhibit V.
22 Exhibit V and Transcript page 97, I note Ms Folwell’s emphatic statement (Transcript pages 54-55) that her daughter
was born at 7.22pm, not four minutes later as recorded in medical records and clinicians’ statements but do not consider the discrepancy Lo be material to the findings T am required to make in the coronial investigation.
283 A/Prof Toale’s views moderated somewhat between his statement (Exhibit F) and his evidence at inquest (Transcript pages 110-202).
24 Vranscript page 427-428.
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accelerations’ around the VE.2> She opined that the pattern was not onc that would necessarily warrant an immediate C-section delivery, even if it were accompanied by a report of RFM. Dr White considered it appropriate to perform an ARM to expedite delivery as would be anticipated to occur in a multiparous woman.”"” She opined that at no time did the CTG tracc or the progress of Ms Folwell’s labour suggest that an immediate Cacsarcan
delivery was necessary.”
95, A/Prof Teale was consistent in his opinion that the CTG trace was ‘a terminal trace’ from the
beginning, such that the outcome for Baby Emma would have been the same even if she had
been delivered earlier. Prof Hyett described the CTG trace as ‘abnormal at all times’ and ‘clearly pathological’.°° Dr Tippett characterised it as ‘abnormal and non-reassuring’ from the outset and then ‘classically’ sinusoidal,°! likening it to the ‘shit traces’ she uses for teaching purposes, described as such because she wants the clinicians who see such traces to react with expletives and take prompt action.>** Prof McDonald was astonished by the lack of understanding of the severity of the trace and the need for urgent action on the part of the
midwives and medical staff.>"
96, Opinion was unanimous that the midwives acted appropriately by escalating their concerns
about the CTG trace to medical staff when they did2“ There was also a clear
95 Transcript page 429.
296 Transcript page 453.
297 Transcript page 456, 288 'I'ranscript page 457.
299 Exhibit F. Dr ‘lippett agreed with this assessment of Raby Emma’s likely clinical course (Transcript page 215).
A/Prot was not critical of either the midwives or medical staff for not recognising the CI'G trace as ‘terminal’ because he considered that the ‘very short-lived’ improvement of the tracc after the ARM would have reassured clinicians, though perhaps more than it should have done (see his statement and Transcript page 174). I note that following a Root Causc Analysis conducted after Baby Emma’s death, all staff involved in Ms Folwell’s management undergo CTG interpretation competency assessment and that all clinical staff were to be reminded to maintain CTG interpretation competency (Exhibits I and G).
30 Exhibit S and Transcript page 464.
ll ranscript page 221-222.
3® Transcript page 222.
303 Exhibit L. Dr ‘I'ippett agreed that is was not clear that anyone, contemporaneously, appreciated the severity of the CTG trace (Transcript page 223).
304 "I'ranscript pages 281-282 (McDonald), 222 (Tippett), 464 (Hyett), and 178-179 (Teale).
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:
| | |
acknowledgement from the experts that, in practical terms, once obstctric staff were involved,
the midwives’ ability to influence clinical decision-making is limited?"
that time and that the most appropriate method of expedition was a Caesarean delivery.°
reasonable to attempt vaginal delivery or anticipate a precipitate one.?!*
99, Inote that notwithstanding his comments about specific decisions made by his medical
staff3!5 during his evidence at inquest A/Prof Teale coriceded that there was ‘delay’*!¢ in
305 Transcript pages 281-282 (McDonald), 223 (Tippett), and 178-179 (Teale).
305 Transcript pages 162 (Teale), 281 (McDonald), 215 & 222 (Tippett), and 464-465 (Hyett).
307 Prof McDonald opined that it was not unreasonable to perform an ARM to check the liquor, however, as ‘nothing changed’ thereafter and in light of the presence of meconium, a Cacsarcan delivery should have occurred thereafter (Transcript page 282),
308 Transcript pages 281 (McDonald), 215 & 222 (Tippett), and 464-465 (Hyett).
5° Transcript page 465.
31° Transcript page 465.
311 The cervix was not sufficiently dilated for foetal blood sampling until about 6.40pm.
312 }oetal blood sampling [FBS], using blood taken from the foetus’ scalp capillaries, allows measurement of the lactate level in blood which is uscd as an indicator of foetal hypoxia. Lactate levels in FBS of less than or cqual to 4. 1mmol/L
are ‘normal’, the range 4.2-4.8mmol/L is ‘pre-acidotic’ and values greater than 4.8mmol/L are indicative of acidosis, requiring immediate delivery of the foctus.
35 Transcript page 466.
314 Transcript page 476.
315 A/Prof Teale made a number of concessions during the course of his oral evidence, He reluctantly conceded that there were some ‘communication concerns’ between midwifery and medical staff (Transcript pages 159-160).
Ilowever, he noted that these had not impeded the midwives’ referral of the concerning CTG trace to the Consultant Obstetrician (Transcript page 179). Thereafter, A/Prof observed that ‘the decision was Dr Jacobs’ to make’ (Transcript
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i
| | | | | | | t
responding to the CTG trace and at 5.30pm he would have performed a VE himself and, if
birth was not imminent, would have proceeded to theatre for a C-section.?!”
umbilical venous*!® and arterial>”°
samples can suggest the origin of an impaired gas exchange and may also indicate whether foetal hypoxia was short-lived or prolonged.?*! A foctus can tolcratc a degree of hypoxia/acidosis during labour and delivery without significant long term consequences. However, pathological acidosis — acidosis beyond which adverse clinical events have a strong probability of occurring, especially if accompanied by abnormal clinical findings at delivery — is indicated by umbilical artery cord blood pH” of less than 7.0 and a
base excess’? of less than -12mmol/L,*”4
hypoxemia immediately preceding birth’.” He considered the low base excess value to be
page 179). He concede that ‘one of the difficulties of the case’ was that Dr Jacobs did not perform a physical examination herself (Transcript page 179).
316 Transcript pages 163.
317 Transcript page 175.
8 Independent Expert Opinion of Neonatologist Dr Philip Henschke dated 13 October 2014 [Henschke report].
319 Acid-basc status of blood sampled from umbilical venous blood predominantly reflects maternal acid-base status.
320 The acid-base slatus of blood sampled from the umbilical artery predominantly reflects foetal acid-base status.
%1 Henschke report. ,
322 bH is a measure of the acidity or alkalinity of a solution. A pH level below the normal reference range for umbilical arterial and venous cord blood samples among infants delivered at or close to term indicates respixatory/metabolic acidosis.
323 Base excess is a calculated measurement of degree of alkalosis or acidosis. It increases or becomes more positive with alkalosis and becomes more negative with increasing acidosis.
394 Thid.
*5 Transcript page 144
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evidence of compensation due to chronic oxygen deprivation.”° Dr Tippett observed that on the basis of the ‘pre-terminal’ CTG trace on presentation at hospital, ‘normal’ cord blood at delivery and the brain injuries identified on MRI, it appeared that the hypoxic cvent did not occur around the time of Baby Emma’s delivery,’ indeed, the normal blood gasses at birth tended to suggest that the foctus had recovered from the hypoxic event metabolically by the time of delivery.”* In contrast, Prof Hyett was concerned about the validity of the cord blood analysis given that the data were internally inconsistent, having features consistent with acidosis, such as low base excess, and other features, such as an apparently normal pH, that
were not?”
Hospital.3*?_He observed that while the venous cord gas parameters fell within the expected
normal range, as the umbilical vein predominantly reflects maternal acid-base status it offered
no assurance that the foctus was not subject to hypoxic-ischaemic stress.*7
sample was contaminated, he opined that it was not possible to consider the recorded arterial
326 Transcript page 139.
27 Transcript page 211.
38 Transcript page 212, 32 Transcript pages 466, 470 and 504, /
30 Venous cord blood analysis returned the following values: pII 7.29, pCOz 31, pO. 45, HCOs 14.6 and BE [base | excess] -10.7mmol/J,, extracted from CB page 144, WH Final Blood Gas report.
33! Arterial cord blood analysis returned the following values: pH 7.30, pCO2 21, pO2 132, IICO; 10.0 and RE - 14mmol/L, extracted from CB page 144, WH Final Blood Gas report.
332 CB page 144, WH Final Blood Gas report.
333 [Tenschke report. : 334 Thid,
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cord pH of 7.30 as a reliable indication of foetal wellbeing during labour and delivery.**° Nonetheless, citing clinical research literature, the neonatologist stated that the base excess value should still provide a reasonably reliable measure of metabolic acidosis.¥* Dr Henschke noted that Baby Emma’s umbilical artery cord blood sample returned a base excess value of -14.0mmol/L and he concluded that even if the specimen was contaminated by air, the findings most likely indicated the presence of significant foetal metabolic acidosis around the time of delivery of a type associated with long term consequences like hypoxic brain
injury.??
labour.**?
Dr Henschke considered that such time frames were only approximate, not precise or specific,
335 Dr Henschke observed that clinical studies had demonstrated that contamination with air can result in the spurious lowering of pCO2 values and a concomitant spurious elevation of pH in cord blood gasses.
336 Henschke report.
337 Tbid.
338 American Conference of Obstetricians and Gynaecologists Task Force on Neonatal Encephalopathy and Cerebral Palsy (ACOG Committee on Obstetric Practice 2005) identified the following criteria as collectively suggesting that an asphyxia event had an intra-partem timing (within 0-48 hours of birth): (1) A sentinel (signal) event occurring immediately before or during labour; (2) A sudden and sustained foctal bradycardia or the absence of foctal heart rate variability in the presence of persistent, late or variable decelcrations usually after a hypoxic sentinel event when the pattern was previously normal; (3) Apgar scores of 0-3 beyond 45 minutes; (4) Onset of multisystem involvement within 72 hours of birth; and (5) Karly imaging study showing cvidence of acute non-focal cerebral abnormality.
38° That is, within close proximity to labour and delivery, zero to 48 hours.
340 Henschke report.
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given the many gaps in scientific knowledge about the nature and progression of cellular
injury secondary to hypoxia.*"!
perinatal period.*#
hypoxic event did not oceur more than 48 hours prior to delivery.*4
of probabilitics, with the Briginshaw gloss or explication.” The effect of the authorities is that Coroners should not make adverse findings against or comments about individuals in
their professional capacities, unless the evidence provides a comfortable level of satisfaction
4! Tid.
32 Tid.
343 CB 54-75, Slatement of Prof Stacey Goergen. I note that Prof Goergen was unable to be more precise about the timing of the brain injuries due to the limitations of the imaging technology (and she noted the echo time used was not that preferred for MRI studies in infants) and the rate of natural evolution of the changes that occur within the neonatal brain after a global hypoxic-ischaemic insult.
44 Exhibit U.
345 Henschke report.
346 Henschke report.
47 Briginshaw v Briginshaw (1938) 60 C.L.R. 336 esp at 362-363. “The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had becn proved to the reasonable satisfaction of the tribunal, In such matters “reasonable satisfaction” should not be produced by inexact proofs, indcfinile testimony, or indirect infererices...”
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109,
that they departed materially from the standards of their profession and in so doing, caused or
contributed to the death.
It is axiomatic that the assessment of clinical management and care must be undertaken strictly without the benefit of hindsight, The trajectory of a patient’s clinical deterioration may well be obvious after the event. Patterns or causal connections that can be traced from the privileged position of knowing the tragic outcome, may not have been obvious or even
appreciable before that outcome.
In terms of the circumstances surrounding the third trimester of Ms Folwell’s pregnancy and Baby Emma’s birth, the clinical management and care provided needs to be assessed against what was known, or should reasonably have been known at the material time, that is when the nursing/midwifery and medical staff were caring for Ms Folwell antenatally and during her
labour.
Having applied the applicable standard to the available evidence, I find as follows:
a. Ms Folwell was a 38-year old, grand multiparous woman with a BMI of 37.
Notwithstanding her risk profile for complications during pregnancy and childbirth there is no evidence to suggest that she should not have received antenatal care through
a midwifery group practice, ‘all risk’ model of care;
b. The antenatal care provided to Ms Folwell until (about) 34 weeks’ gestation was
reasonable and appropriate;
c. The performance of an ultrasound in June at near enough to 34 weeks’ gestation was in accordance with the WH guidelines for high BMT women and the results were
reassuring in terms of foetal growth;
d. The lack of clinical response to the documented relatively static fundal height measurements between 34 and 38 weeks’ gestation was suboptimal and amounted to a missed opportunity for obstetric review and, potentially, earlier intervention and a
different outcome for Baby Emma;
c. Record-keeping of Ms Folwell’s antenatal care was suboptimal. While mothers may appreciate having a Maternal Health Record with basic details of their antenatal course as a kecpsake, the practice of clinical staff relying on the record which remains in the possession of the mother is fraught and the details noted in it are inadequate as a clinical
record of the antenatal care provided.
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On 26 July 2011, Ms Folwell was appropriately asked by RNM Currie to attend Sunshine Hospital for CTG monitoring to assess foetal well-being in response to her report of reduced foetal movements made that day. I am unable to determine if Ms Folwell made an earlier report to RNM Currie of reduced foctal movements at her last
antenatal visit on 25 July 2011 and if that report went unheeded.
Upon Ms Folwell’s presentation to the assessment centre, the decisions made by the RNMs between about 5.00-5.25pm, to apply a CTG, perform a vaginal examination to assess labour and foetal well-being and then to continue to monitor the CTG for some
minutes before referral for Obstetric input were reasonable and appropriate.
By the time of Obstetric review by Dr Jacobs at about 5.25pm, competent interpretation of the CTG trace in the context of all the circumstances should have led to expedited delivery. As Ms Folwell was not in established labour, for all her multi-
parity, a delivery by Cacsarean section was indicated.
Alternatively, at 5.25pm, artificial rupture of the membranes and the placement of a foetal scalp electrode to verify the abnormality of the CTG trace would not have been unreasonable so long as there was close Obstetric monitoring and a timely clinical response to any findings. In any event, by 6.00pm, there was ample justification for an
emergency Caesarean section.
respective of whether the decision to proceed to Cacsarcan section was made at 5.25pm or by 6.00pm, Baby Emma would have been born earlier than she was by between 60-90 minutes,
Taken as a whole, the evidence amply demonstrates poor communication, poor collaboration and poor documentation of Ms Folwell’s labour and delivery by RNM and
Obstetric staff involved.
The hypoxic event that resulted in Baby Emma’s severe brain injury occurred within a window of zero to 48 hours prior to her birth and the evidence does not allow me to
make a morc precise finding as to the timing of the event.
Thus I am unable to make a finding that any of the inadequacies of clinical management or care provided to Ms Fowell caused or contributed to Baby Emma’s death. While the evidence does not support a finding that it is probably so, it is not possible to exclude the possibility that earlier intervention may have led to a different
outcome.
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n. That said, the poor communication and collaboration between clinicians evident here, could well cause or contribute to adverse outcomes in other circumstances, and cannot
therefore be condoned in the interests of future paticnt safety.
I direct that a copy of this finding be provided to:
ae enone CX ar A
ia
Baby Emma’s parents
Western Health, c/- TressCox Lawyers
Royal Women’s Hospital
Dr Christine Tippett, Obstetrician/Gynaecologist Dr Stacy Goergen, Radiologist
Professor Susan McDonald, Professor of Midwifery, La Trobe University Dr Amanda J. Sampson, Radiologist, Women’s Ultrasound Melbourne Dr Phillip Henschke, Neonatologist
Consultative Council on Perinatal Morbidity and Mortality
Signature:
PARESA ANTONIADIS SPANOS Coroner Date: 30 January 2017
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