Deceased
Finn Moser
Demographics
1y, male
Coroner
Coroner Simon McGregor
Date of death
2017-01-11
Finding date
2019-11-11
Cause of death
Head injury in the setting of labour
AI-generated summary
Finn Moser was a one-day-old neonate who died from head injury sustained during labour and delivery at the Royal Women's Hospital. He was born to a mother with dichorionic diamniotic twins, induced at 36 weeks due to presumed growth discordancy (subsequently recalculated as concordant). Labour progressed slowly, and caesarean section was undertaken. During extraction, Finn's head was deeply impacted in the maternal pelvis requiring difficult disimpaction and extraction, resulting in bilateral subdural haematomas, subarachnoid haemorrhages and skull fracture. Multiple clinical management issues were identified: miscalculation of fetal weight discordancy, discontinuation of fetal monitoring during transfer to theatre, failure to perform pre-operative vaginal examination to assess fetal head position, and absence of consultant obstetrician supervision during a potentially difficult delivery. The RWH and the College were recommended to review guidelines and educational practices regarding detection and management of impacted fetal heads.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT Court Reference: COR 2017 0191
Form 38 Rule 60(2) Section 67 of the Coroners Act 2008
Amended pursuant to section 76 of the Coroners Act 2008 on 11 November 2019
Findings of: Simon McGregor, Coroner Deceased: Finn Moser
Date of birth: 10 January 2017
Date of death: 11 January 2017
Cause of death: Head injury in the setting of labour Place of death: The Royal Women’s Hospital
20 Flemington Road, Parkville Victoria 3052
Finn Moser was a one-day-old baby who was born at the Royal Women’s Hospital (RWH) located at 20 Flemington Road, Parkville Victoria 3052 on 10 January 2017.
There were complications during Finn’s delivery and shortly afterwards he was found to have
suffered brain injuries. He did not recover and died on 11 January 2017.
‘reportable death’ for the purposes of the Coroners Act 2008.
criminal or civil liability.
under investigation.
pathologist who examined Finn and the investigating officer.
Weaver. Finn’s family also submitted additional materials.
relevant to my findings or necessary for narrative clarity.
jurisdiction facts must be established on the balance of probabilities.!
Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.
(DCDA) in 2016 and had an estimated due date of 1 February 2017.7
Fetal weight discordancy and recommendation for induction
and 2.850kg for the other. This placed the first fetus in the 45" percentile for growth and the second in the 80% percentile. The images of the first twin were limited due to the deep
engagement of the fetal head.*
from the weight of the larger twin and dividing by the weight of the larger twin. Based on
these measurements of fetal weight, the fetal weight discordancy was approximately 14.1%.°
Hospital staff calculated the fetal weight discordancy incorrectly, arriving at a figure of 20%.°
A fetal weight discordancy of more than 20% is considered a cause for concern, and so staff
recommended induction of labour.’ A plan was made to admit Ms Chisholm to hospital on
9 January 2017.8
ee ar
This is subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.
A DCDA twin pregnancy is where each twin has its own chorionic and ammiotic sacs and results from the fertilisation and development of two eggs. As such, each fetus has a placenta.
Statement of Professor Mark Umstad dated 26 April 2018, Coronial Brief.
Statement of Professor Mark Umstad dated 3 October 2018, Coronial Brief.
Ibid.
Ibid.
Ibid.
Statement of Professor Mark Umstad dated 26 April 2018, Coronial Brief.
Admission to the Royal Women’s Hospital
22,
Ms Chisholm was admitted to the RWH at 7.40am on 9 January 2017. She was counselled about the need for her twins to be born as Finn’s growth appeared to be slowing. At 9.00am,
induction began using prostaglandin gel.?
At 4.30pm on 9 January 2017, the amniotic sac around Finn was ruptured. The fluid was clear and copious, which is considered a good sign, and fetal monitoring was normal. Ms Chisholm was transferred to the Birth Centre and commenced on antibiotics. At 5.25pm, she was put on
an infusion of Syntocinon (oxytocin) to stimulate labour.'°
Over the night of 9-10 January 2017, Ms Chisholm’s labour progressed slowly and her contractions were incoordinate. The dosage of Syntocinon was steadily increased in an
attempt to overcome this.!!
At 8.00am on 10 January 2017, Ms Chisholm’s care was handed over to consultant obstetrician, Dr Julia Unterscheider and Dr Mei Lin Tan, a senior registrar in obstetrics and gynaecology. On this day, Dr Kelly van den Haspel!* was working as a junior registrar with
Dr Unterscheider and Dr Tan.4
Dr Unterscheider was informed that Ms Chisholm was undergoing induction of labour for presumed discordant growth. At this time, Dr Unterscheider recalculated the growth discordance between the twins. She arrived at a figure of approximately 15%, representing
concordant growth rather than discordant growth.'4 Ms Chisholm stated that this recalculation was never discussed with her.'*
Fetal heart rate was being monitored using cardiotocography (CTG). Dr Unterscheider reviewed Finn’s CTG trace (the record of his heart rate over time) during the handover. She
considered that the CTG trace was normal.!¢
° Expert Report of A/Prof Edward Weaver dated 4 July 2018, Coronial Brief.
10 Tbid.
" Thid.
Dr van den Haspel was an obstetrics and gynaecology registrar, level 2.
13 Statement of Dr Julia Unterscheider dated 13 March 2018, Coronial Brief; Statement of Dr Mei Lin Tan dated 13 March 2018, Coronial Brief; Statement of Dr Kelly van den Haspel dated 9 March 2018, Coronial Brief.
'4 Statement of Dr Julia Unterscheider dated 13 March 2018, Coronial Brief.
‘5 Bree Chisholm’s Response to the Coronial Brief.
18 Statement of Dr Julia Unterscheider dated 13 March 2018, Coronial Brief.
section unless there was a significant change in cervical dilation.!7
24, At 8.43am, Ms Chisholm was reviewed by Dr van den Haspel.!®
25, Dr van den Haspel found that Ms Chisholm was 4 centimetres dilated, that her cervix was 0.5 centimetres long with a medium consistency and that Finn was at station-2 with mild caput but no moulding apparent. Dr van den Haspel also reviewed the CTG trace for both twins and
found both traces reassuring.”
of delivery.”!
section was appropriate.”
arrangements for the caesarean section were made.”
‘Code Green’ immediate delivery.”
being transferred to the operating suite.”
1 Thid.
18 Statement of Dr Kelly van den Haspel dated 9 March 2018, Coronial Brief.
9 Tbid.
20 ‘Maximum strength’ is 96ml/hr of 20U Syntocinon in 1 litre normal saline.
2 Statement of Dr Kelly van den Haspel dated 9 March 2018, Coronial Brief.
2 Statement of Dr Mei Lin Tan dated 13 March 2018, Coronial Brief.
3 Statement of Dr Kelly van den Haspel dated 9 March 2018, Coronial Brief.
24 Thid.
33 Thid.
Transfer to Operating Theatre and delivery
34,
Midwifery staff attended at 9.53am to transfer Ms Chisholm to the operating theatre. The CTG monitor was taken off Ms Chisholm before her transfer.”°
Dr Unterscheider decided that, as Dr Tan was an experienced registrar in her final year of training, Dr Tan was sufficiently competent to carry out the delivery by caesarean section
without direct supervision.”
Dr Unterscheider and Dr Tan discussed that there was a heightened risk of post-partum haemorrhage in this birth, and Dr Tan ensured that the necessary equipment and medications
were in the theatre to manage any post-partum haemorrhage.”®
Present in the delivery room were Dr Tan, Dr van den Haspel, anaesthetist Dr David Morgan,
members of the paediatric team and several nurses and midwives.”
After Dr Morgan had put a spinal block in place, Dr van den Haspel performed another vaginal examination and confirmed that Ms Chisholm was 4 centimetres dilated. She did not see any indication that the first twin, Finn, might have an impacted head. Dr van den Haspel then
commenced a caesarean section, under Dr Tan’s supervision?
Once Dr van den Haspel had opened the uterus, she recognised that Finn’s head was deeply impacted in the maternal pelvis, moulding was present and Finn’s head was in a deflexed position. Dr van den Haspel attempted to remove Finn’s head from the pelvis with gentle upward traction for approximately one minute, with no success. Dr Tan then took over the
delivery from Dr van den Haspel,*!
Dr Tan requested that Dr Unterscheider be contacted. At around this time the uterus underwent a tonic contraction, obstructing access to Finn. Dr Tan asked Dr Morgan to administer
Glyceryl Trinitrate (GTN) to relax the uterus. A ‘Code Pink’ was then called for urgent
26 Statement of Dr Mei Lin Tan dated 13 March 2018, Coronial Bricf.
27 Statement of Dr Julia Unterscheider dated 13 March 2018, Coronial Brief.
28 Statement of Dr Mei Lin Tan dated 13 March 2018, Coronial Brief; Statement of Dr Julia Unterscheider dated 13 Match 2018, Coronial Brief.
8 Statement of Dr Mei Lin Tan dated 13 March 2018, Coronial Brief.
2° Thid.
31 Statement of Dr Kelly van den Haspel dated 9 March 2018, Coronial Brief.
obstetric assistance. This occurred approximately one minute after Dr Tan requested that Dr
Unterscheider be contacted.*?
At Dr Tan’s request, a midwife began assisting to disumpact Finn’s head vaginally. By a combination of disimpaction vaginally and delivery through the caesarean incision, they were
able to disimpact Finn’s head to the level of the pelvic brim, making his face visible.?
Dr Tan then attempted a delivery using forceps, but due to the position of Finn’s head she was
unable to place the forceps properly.**
Another consultant obstetrician, Dr Boski Shah, arrived due to the ‘Code Pink’ emergency call and assisted with the delivery. Dr Shah was able to complete Finn’s delivery and hand him to the paediatric team, approximately four minutes after Dr van den Haspel had first
opened the uterus.*°
Finn’s twin brother, Lenny, was then delivered without complication.*®
Neonatal care
44,
Finn was immediately taken to a resuscitation cot and cardiopulmonary resuscitation (CPR) was commenced. Finn began breathing regularly around thirty minutes after his birth and he was taken to the Neonatal Intensive Care Unit (NICU).?”
A cranial ultrasound performed later on 10 January 2017, showed swelling of the brain and impaired cerebral blood flow. A brain magnetic resonance imaging scan on 11 January 2017 showed signs of brain injury consistent with brain death. The neonatal consultants determined that the prognosis was ‘extremely grim’ and that death or severe disability was an expected.
outcome.*8
After discussion with Finn’s parents, the decision was made to palliate Finn and he died in his
parents’ arms.
3»? Statement of Dr Mei Lin Tan dated 13 March 2018, Coronial Brief.
3 Ibid.
4 Thid.
35 Statement of Dr Mei Lin Tan dated 13 March 2018, Coronial Brief; Statement of Dr Kelly van den Haspel dated 9 March 2018, Coronial Brief.
36 Thid.
7 Royal Women’s Hospital Medical Records.
38 Thid.
On 11 January 2017, Frank Moser visually identified Finn’s body. Identity is not in dispute and requires no further investigation.
On 13 January 2017, Dr Sarah Parsons, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an autopsy upon Finn’s body and reviewed a post mortem computed tomography (CT) scan. Dr Parsons completed a report, dated 8 May 2017, in which she formulated the cause of death as ‘7(a) Head injury in the setting labour’.
Dr Parsons noted that Finn’s head injuries included bilateral subdural haematomas, patchy subarachnoid haemorrhages, a cephalohaematoma, a subgaleal haematoma and a linear skull fracture.
Dr Parsons further commented that whether the injuries are due to the head being stuck in the pelvis or being pushed against the pelvis during uterine contraction, or whether it is due to disimpaction of the head from the pelvis is unclear.
Due to the possibility that Finn’s death might have been preventable, this matter was referred to the Coroners Prevention Unit (CPU)? for a review of the care provided by the RWH.
The CPU obtained statements from clinicians involved in Finn’s delivery. They also received a statement from Professor Mark Umstad of the RWH, describing the results of an internal review undertaken by the RWH after Finn’s death.
Onthe CPU’s advice, an expert opinion on the management of maternity care provided to Ms
Chisholm was requested from Associate Professor Edward Weaver of the University of Queensland. A/Prof Weaver supplied a report dated 4 July 2018, identifying several issues with the RWH’s management of Ms Chisholm’s labour and delivery.
3° The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the Coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the coroner.
The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.
A copy of this opinion was provided to the RWH. Prof Umstad provided a supplementary statement in response to the opinion, detailing that he believed that A/Prof Weaver’s report
was accurate and well considered.”
Antenatal care
A/Prof Weaver found that the antenatal care throughout Ms Chisholm’s pregnancy was provided to a good standard and that it was reasonable to induce her at nearly 37 completed
weeks of gestation, considering clinical concerns about Finn’s growth.
He noted that the decision to schedule induction of labour on 9 January 2017 was based, in part, on a miscalculation of growth discrepancy. Despite this, he still considered that it was
reasonable to induce labour due to reasonable concerns about Finn’s reduced growth velocity.
Management of labour
In A/Prof Weaver’s opinion, the overall labour management plan for Ms Chisholm was reasonable and well within a normal standard of practice. He believes that the use of Syntocinon and the management of the infusion was appropriate and well within an acceptable standard of care. Medical notes did not provide A/ Prof Weaver with any evidence that there
was an indication for earlier delivery.
He considers that it was reasonable for Ms Chisholm to attempt a vaginal birth, given that her babies were coping well with labour. When it seemed obvious that labour progress was
arrested, the treating team proceeded with a caesarean section.
A/Prof Weaver detailed that in his opinion, there were several reasons why Ms Chisholm’s labour progressed slowly. These included that it was her first labour, she was pre-term, she was induced and Finn was in a right occipito-posterior*! position. He stated that it was reasonable to allow her sufficient time in labour to see if she could deliver her babies vaginally. When labour stalled, she was rightly consented for a caesarean section and that this
was done in a timely fashion.
4° Supplementary statement of Professor Mark Umstad dated 3 October 2018, Coronial Brief.
4! The occiput or back of the fetus’ head lies in the posterior rather than the anterior part of the pelvis. As a consequence, the fetal head is deflexed. Deflexed means the head is not flexed, optimally babies have a flexed head (chin to chest) when delivered vaginally.
continuing with the infusion.
Despite this, he does not consider the continuation of the Syntocinon infusion for the approximate two hours that it took to transfer Ms Chisholm to the operating theatre, to have made a difference to the degree of impaction of Finn’s head. This is especially so, given that Ms Chisholm had already been receiving the Syntocinon infusion for the preceding 15 hours, with little progress.
A/Prof Weaver considered the vaginal examination findings in theatre to be noteworthy.
Specifically, that they were unchanged, with Ms Chisholm’s cervix remaining at 4 centimetres of dilation, and Finn’s head being located at ‘station-1’*3, Effectively, this meant that Finn’s head had been forced into a tight space by the contractions of the uterus but it was not fixed
there and should have been able to have been ‘un-wedged’ via suitable techniques.
difference to the outcome.
but does not detract from the issue that fetal monitoring during the transfer period should have
‘43 Meaning that the head was positioned 1 centimetre above the ischial spines, bony landmarks situated in the mid pelvis.
continued to ensure that acute fetal distress did not occur, necessitating a more urgent
classification.
Fetal monitoring
CTG monitoring was commenced at 9.00am on 9 January 2018. Medical notes show various tracings covering the period Ms Chisholm was induced through to her labour. The CTGs are all ‘essentially normal’, however on occasions there were periods of tachysystole, where Ms Chisholm’s uterus was having five to six contractions every ten minutes. A/Prof Weaver noted that during these periods, there was no indication of any associated fetal compromise.
Therefore, these tracings should be classified as abnormal but unlikely to be associated with
any fetal compromise.
A/Prof Weaver further stated that there were several indications for continuous electronic fetal monitoring in labour, as per the College’s Intrapartum Fetal Surveillance, Clinical Guidetine
(the guideline). Specifically, Ms Chisholm had the following indications:
(a) DCDA twins;
(b) induction of labour;
(c) intra-uterine growth restriction; and
(d) _ the use of oxytocin during labour.
The guideline also state:
The fetal heart rate should be monitored by intermittent auscultation during unavoidable interruptions, at times of potential fetal vulnerability, with re-commencement of continuous CTG when feasible.
Interruptions to fetal monitoring should be minimised during transfer to the operating theatre and prior
to delivery of the fetus.
Given these indications, A/Prof Weaver considered that monitoring should have been conducted throughout labour and should have continued during Ms Chisholm’s transfer to the operating theatre through to the commencement of the caesarean section. He further noted that given Ms Chisholm was still receiving Syntocinon, it was important to ensure that Finn’s
condition** was satisfactory prior to the commencement of the caesarean section.
45 The leading twin and the twin with intra-uterine growth restriction, who was more at risk of intrapartum fetal distress.
70,
Professor Umstad’s supplementary statement details that it is the RWH’s standard practice to continue with fetal heart rate monitoring between the time of transfer from the Birth Centre to the commencement of surgery, including in the holding bay. He further details that a
portable CTG monitor is available to facilitate such monitoring.*°
Professor Umstad agreed that it would have been ‘preferable’ for the continuation of monitoring of Finn’s heart rate between the time Ms Chisholm was transferred to the holding
bay and the commencement of the caesarean section.”
A/ Prof Weaver opined that it is impossible to say whether or not Finn was already in distress when the caesarean section was commenced due to this lack of monitoring.” If Finn was distressed during this time, then it is possible that this could have contributed to his death. The
extent of this possible contribution is impossible to determine.
Caesarean section and delivery
It is known that extraction of the fetal head can be problematic at emergency caesarean section. A/Prof Weaver noted that in this case, Ms Chisholm was only 4 centimetres dilated, with the last recorded station of Finn’s head being station-1 (not low). Given that the pregnancy was a twin pregnancy at just under 37 weeks gestation, it was reasonable to assume that Finn was relatively smaller than a singleton pregnancy at a comparable gestation. In addition, Finn was lying longitudinally (normal). Ms Chisholm’s body mass index was normal and she had had no prior surgery. None of these factors suggested a potential for operative
difficulties.
When the vaginal examination was conducted prior to the caesarean section, in addition to the status of Ms Chisholm’s dilation status, the position of Finn’s head with respect to Ms Chisholin’s pelvis should have also been determined. It is not clear from medical notes that
this occurred.
During labour, Finn’s head was recorded as being in an occipito-posterior position. If that was still the case at the time of the vaginal examination, this should have been communicated to
Dr Tan. An occipito-posterior position was likely to make extraction of the fetal head more
46 Statement of Professor Mark Umstad dated 3 October 2018, Coronial Brief.
4" Thid.
48 Noteworthy, even though this scenario is unlikely, given that the CTG trace was normal when it was ceased.
74,
difficult. Such information may have resulted in a consultant being present in theatre at the
outset of the caesarean section.
A/Prof Weaver was specific that he did not consider Ms Chisholm’s labour to have been obstructed. He considers that her labour did not progress because of a combination of incoordinate contractions” and a mal-position of Finn’s head. As detailed above, it is unclear if the doctors performing the caesarean section were cognisant of Finn’s occipito-posterior
position and the potential difficulties that may be encountered as a result.
A/Prof Weaver was satisfied with Dr Untersceider’s opinion that Dr Tan was sufficiently experienced to carry out the delivery without supervision. Specifically, given that Dr Tan was an experienced registrar in her final year of training, this was a reasonable view to have taken.
He does however, detail that it is important that a registrar performing a caesarean section has a clear idea of why labour has not progressed. Subsequently, A/ Prof Weaver believes that it was imperative that the vaginal examination was performed immediately prior to the
commencement of the caesarean section.*°
Presence of a consultant obstetrician
A/Prof Weaver noted that he considers it unusual that the doctors in this case had such difficulties in delivering Finn’s head. Given that it was only located at station-1 and Ms Chisholm was only 4 centimetres dilated, he would have expected such a procedure to be
straightforward.
It was A/Prof Weaver’s opinion, that it is sound clinical practice and good risk management for a consultant obstetrician to be present in the theatre during cases when there is a reasonable expectation that difficulties could be encountered. At the very least, he stated that there should always be provision in any teaching hospital for a registrar to request a consultant to be present
when performing a potentially complex caesarean section.
® The midwives’ notes incoordinate contractions on a number of occasions and correctly increased the Syntocinon infusion rate in an attempt to overcome the problem.
*° This would have alerted the surgeon to any unanticipated progress in labour, allowed a check of the station of the fetal head and enabled the surgeon to determine the position of the fetal head with respect to the pelvis and its degree of de-flexion.
Specifically, situations where a consultant obstetrician is expected to attend are prescribed in
RWH’s protocol, Hscalation to Senior Medical Staff Rostered to Birth Centre.
While a consultant was not present from the outset of surgery, A/ Prof Weaver noted that when Dr Tan could not deliver Finn and had exhausted ail options, it was right to stop and
request consultant attendance.
and credentialing.
Cause of Finn’s injuries
nor had he heard of such an occurrence. He concluded:
I think the injuries were most likely to be caused by the various actions used in elevating and delivering
the fetal head, though it is impossible for me to say which practitioner caused such injuries.
Royal Women’s Hospital response to death Internal Review
(a) The Department of Ultrasound at the RWH should reinforce the correct calculations of
growth discordance in twins with all relevant clinicians.
5! Statement of Dr Julia Unterscheider dated 13 March 2018, Coronial Brief.
(b) To optimise paticnt outcomes and to facilitate teaching opportunities, the Birth Centre obstetric consultants will be instructed about their attendance at potentially difficult
births and deliveries.
(c) Vaginal examinations prior to operative deliveries in the operating theatre are to be
performed by the most senior obstetric clinician present.
(d) The medical practitioners involved have been provided with education about additional
techniques for disimpaction of the fetal head. This education will continue to be
provided to all obstetric trainees.
(e) Disimpaction of the fetal head is to be performed by the most senior ostetricion present.
(PH The guidelines for obstetric consultant presence at caesarean section will be reviewed
by the Division of Maternity Services.
All recommendations were noted as having been actioned and a new guideline having been developed, Impacted Fetal Head at Caesarean Section — Management. A copy dated 8 April 2018 of this guideline was provided to the Court.
A/Prof Weaver agreed with the conclusions reached by the RWH’s internal review of Finn’s case, commenting that they were reasonable. He added that his additional recommendation would be the implementation of a clear centralised credentialing system for obstetric trainees in the performance of complex caesarean sections. Such a system would allow consultant obstetricians to have current information on registrars’ scope of practice. Regular updates
every six months would contribute to individual registrar’s summative assessments.
Response to A/Prof Weaver’s expert opinion
The RWH agreed with A/Prof Weaver’s recommendations. According to Prof Umstad, they
are actioning the recommendations as follows:
(a) A clearer process for credentialing and signing off the competence of individual
registrars to perform complex caesarean sections, is presently under development.
(b) Once finalised, this credentialing process will be updated every six months at the time
of each registrar’s summative assessment.
(c) This list will be available in the operating theatre suite and the Birth Centre for ease of reference via the intranet and via a hardcopy that is readily accessible. The intranet has been chosen as it is available to all staff: midwifery, nursing and obstetric at all access points within the hospital which includes the operating suites, Birth Centre, antenatal wards and emergency department. It is also accessible for consultants who are offsite at
the time.
Irequest confirmation of the above for the Court’s record.
Coronial Context
In 2017, the Queensland Deputy State Coroner Lock conducted an Inquest* into a perinatal death resulting from birth injuries following an obstructed labour. The finding recommended that the College update the guideline, Delivery of the fetus at caesarean section to include a description of techniques that may be adopted to deliver a fetus with a deeply impacted head.
A revised version of the guideline was published in July 2017.
While I recognise that based on the evidence before me, Ms Chisholm did not suffer from an obstructed labour, there is nonetheless a common issue of a deeply impacted fetal head in the pelvis that required vaginal disimpaction and a technically difficult extraction at caesarean
delivery.
The recommendation in this guideline is for the elevation of the fetal head vaginally by an
experienced assistant. In this case, it was performed by a midwife.
The revised guideline was not available at the time of Finn’s birth however, I am satisfied that had it been available and had it been followed, the outcome may have been different. The
revised guideline cites “some evidence that inflatable devices might reduce the risk of uterine injury’.
On 18 September 2019, the Victorian Acting State Coroner, Caitlin English, handed down her findings”? into a perinatal death resulting from complications of an impacted fetal head at full
dilation. In the course of her investigation, expert advice was obtained recommending that-the
College consider evidence on inflatable devices in the minimisation of fetal head injuries.
% Acting State Coroner Caitlin English Finding into Death without Inquest, Lucia Grace Sefton (Bowlen) [2015 3982].
The College responded to this proposed recommendation by detailing that there is some evidence that inflatable devices might reduce the risk of uterine injury but that there is no high-quality evidence of a reduction in fetal head trauma and limited evidence of any clinically significant neonatal benefit. They further commented that the studies of the use of inflatable devices do not include enough women at preterm gestations to determine their role in such situations. They noted that, although such devices may be of benefit, its use in preterm deliveries is currently unproven and should remain at the discretion of the treating clinician.™ Specialist review of this response considered it to be reasonable overall, given that the College
can only recommend changes based on evidence.
I consider that following Finn’s case, it would now be of assistance for the College to review the evidence on techniques and devices to reduce head injuries. I note the RWH currently uses
the fetal pillow inflatable device*.
4 Thid.
Taccept A/Prof Weaver’s conclusions in his report.
I recognise that the RWH have acknowledged issues with their practices that played a role in Finn’s death, and have implemented recommendations from their internal review to improve
the care they provide in the future.
After addressing Finn’s case in his expert report, A/Prof Weaver noted his concern that there have been increasing numbers of cases like Finn’s reported in recent ycars, while prior to 2009 he had never heard of a baby dying from a skull fracture following a difficult extraction at
caesarean section.
Finn’s death highlights the importance of diligent monitoring of labour progress and early involvement of experienced consultant obstetricians. I consider that education is required to improve detection of a technically difficult extractions during caesarean deliveries and ensure that the doctors involved are practiced in the correct manoeuvres that may be required to minimise injury to the mother and baby. For these reasons, I will be referring this finding to
the College for consideration as to any lessons that can be learnt from Finn’s death.
% A balloon device designed to elevate a deeply impacted head out of the pelvis marketed as a Fetal Pillow®.
likelihood of deaths such as Finn’s, and I will make recommendations below to this effect.
experienced obstetrician present.
following issues:
(a) early identification and escalation to consultant obstetric staff of obstructed labour or
potentially difficult fetal head extractions during caesareans;
(b) tnulti-disciplinary scenario based training, such as Practical Obstetric Multi Professional Training (PROMPT)56 that includes techniques to be adopted for safe delivery of the baby where the head is deeply impacted in the pelvis. This should be targeted to obstetric medical staff as part of all obstetric training programs;
(c) the risk of head injuries, particularly skull fractures and significant bleeding, in relation to obstructed labour and vaginal disimpaction; and
(d) continuous fetal monitoring, particularly in theatre and up until the time of caesarean.
The RWH should ensure continuous fetal monitoring is part of their clinical guidelines.
disimpaction.
section, to specify:
56 Bvidence based multi-professional training for obstetric emergencies.
{a)
(b)
that vaginal examinations immediately prior to commencing a caesarean section should
be performed by the most senior obstetric clinician present; and.
inclusion of the College’s recommendations into the mandatory surgical, safety ‘timeout’ checklist®’, which is completed prior to commencement of all procedures, In particular, it should specify the need for a vaginal examination prior to commencing a caesarean section and the identification of obstructed labour or a difficult head extraction. If this is identified or suspected, the multi-disciplinary team in theatre need to be aware of their roles, responsibilities and the techniques to be employed. A discussion on the manoeuvres that may be required could be part of the surgical safety
‘timeout’ checklist.
RANZCOG Training Registrar Supervision Guideline. The Guideline was published after
Finn’s death and addresses issues of supervision and credentialing.
57 A World Health Organisation (WHO) Surgical Safety Checklist to increase the safety of patients undergoing surgery by systemic checking to ensure conditions are optimal for patient safety. The surgical ‘timeout’ is performed by the surgeons, anaesthetist and theatre nurses in the operating theatre immediatcly before a planned procedure. At the time a person is brought into theatre, the surgical team pauses to confirm patient identity, surgical site and planned
procedure.
Pursuant to section 73(1B) of the Act, I direct that this finding be published on the Internet.
Having investigated the death, without holding an inquest, | make the following findings pursuant to section 67(1) of the Coroners Act 2008:
(a) The identity of the deceased was Finn Moser, born 10 January 2017;
(b) The death occurred on 11 January 2017 at the Royal Women’s Hospital located at 20 Flemington Road, Parkville Victoria 3052 from a head injury in the setting of labour;
and
(c) The death occurred in the circumstances described above.
(a) Ms Bree Chisholm, senior next of kin
(b) = Mr Frank Moser, senior next of kin
(c) Ms Dimitra Dubrow, Maurice Blackburn Lawyers on behalf of Bree Chisholm, interested party
(dq) Ms Janine Mellwraith, Slater and Gordon on behalf of Frank Moser, interested party
(e) Ms Lisa Ridd, MinterEllison on behalf of the Royal Women’s Hospital, interested party
(f) Professor Mark Umstad, Royal Women’s Hospital, interested party
(g) Dr Julia Unterscheider, Royal Women’s Hospital, interested party
(h) Dr Mei Lin Tan, Royal Women’s Hospital, interested party
G) Dr Kelly van den Haspel, Royal Women’s Hospital, interested party
G) Dr Sue Matthews, Chief Executive, Royal Women’s Hospital, interested party**
58 Amended to reflect the name of the current Chief Executive of the Royal Women’s Hospital. Internally identified on 7 November 2019.
(k) Dr Vijay Roach, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, interested party
(1) Adjunct Professor Tanya Farrell, Consultative Council on Obstetric and Paediatric Mortality and Morbidity, interested party
(m) Professor Euan Wallace, Safer Care Victoria, Victorian Department of Health and
Human Services, interested party (®) Nursing and Midwifery Board of Australia, interested party
(0) Senior Constable Hanna Smith, Coroner’s Investigator.
Signature:
\ SIMON McGREGOR
CORONER Date: 11 November 2019
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