Record OF Investigation Into Death
Coroners Act 1995
Coroners Regulations 1996
I, Rod Chandler, Coroner, having investigated the death of
Luc Ryan na CHAMPASSAK
WITHOUT HOLDING AN INQUEST
Find That :
Luc Ryan na CHAMPASSAK ("Luc") died on 8 March 2007 at the Royal Hobart Hospital ("the RHH") in Hobart. Luc was aged 1 day, having been born on 7 March 2007.
I further find that Luc's death was a Sudden Unexpected Death in Infancy with pneumonitis from inhaled squamous epithelial cells being the main contributing factor.
Luc was born at the Hobart Private Hospital ("the Private") at 9.06 pm on 7 March 2007. His parents are Philippe and Amanda na Champassak. At about 2.00 pm on 8 March Mrs na Champassak placed Luc in his cot beside her bed after he had been bathed and had then fallen asleep. Mrs na Champassak then slept herself waking at about 4.00 pm. She noted that Luc appeared to be sleeping soundly. She picked him up and he did not rouse. She feared something was wrong. She immediately took Luc to a midwife who noted absent breathing and absent heart sounds. Resuscitation was commenced and Luc was transferred to the Neonatal Intensive Care Unit at the RHH. Luc could not be revived despite ongoing resuscitative efforts and he was declared deceased at 4.20 pm.
Forensic Pathologist, Dr D M Ritchey, carried out a post-mortem examination. He concluded that Luc had died from acute bronco-pneumonia. Dr Ritchey made this specific observation, "The lungs were heavier than normal and the air sacs contained patchy neutrophils (acute pneumonia) and squamous debris (aspirated epithelial cells). These findings strongly suggest acute pneumonia as the cause of the death. The presence of aspirated squamous epithelial cells suggests that aspiration may have contributed to the development of pneumonia."
Luc's death has been the subject of a detailed investigation. As part of that investigation a report was sought from Dr Neil Roy, a Consultant Neonatal Paediatrician. In addition, the investigation has been aided by the provision of a report from Dr George Williams, a Paediatrician/Perinatologist retained by Luc's parents.
Circumstances Surrounding the Death
The Pregnancy and Birth
Mrs na Champassak fell pregnant with Luc when holidaying in Europe. At this time she was a resident of Canberra. Luc was her third child. The family moved to Hobart on 13 January 2007 when Mrs na Champassak was at 34 weeks gestation. From that date her antenatal care was managed by Obstetrician/Gynaecologist, Dr Lisa Turner.
Mrs na Champassak's antenatal course was normal. However at 39 weeks her blood pressure was raised at 150/100 and it was decided that she should be admitted to hospital for induction of labour. Mrs na Champassak presented at the Private at 8.45 pm on 6 March 2007 and the induction process was commenced by Dr Turner with the use of Prostin. On the morning of 7 March the membranes were artificially ruptured by Dr Turner and from 12.45 pm Syntocinon was administered to assist with the induction process. As will be discussed later cardiotocograph (CTG) recordings were not made after the introduction of Syntocinon. During the course of her labour Mrs na Champassak was administered two doses of pethidine, the second two hours prior to delivery.
Luc was born by vaginal delivery at 9.06 pm on 7 March. There was mild shoulder dystocia and he was delivered by McRoberts manoeuvre. His birth weight was 3.910 kgs and his Apgar scores were 9 at both 1 minute and 5 minutes. Breathing was established at 10 seconds without resuscitation being required.
Mr and Mrs na Champassak have provided a very comprehensive account of events for the entire period leading up to Luc's death. Nursing staff have also provided written statements. In addition I have had access to the Private's records. A critical issue for me to consider in the examination of this material is whether Luc was suffering respiratory distress during his brief life.
Ms Joanna Summers is a registered midwife who was attending Mrs na Champassak during her labour. It is the parents recollection that Ms Summers had commented shortly after the birth that she thought Luc's breathing was laboured and that he should be examined by a paediatrician. They say that Dr Turner agreed with this. However, this is inconsistent with statements made by Ms Summers and Dr Turner. The former, in her statement, says that after his birth Luc was "placed onto Amandas chest and appeared to breathe normally. I did however note at this stage that the babys face was contused, which is quite normal after a delivery. Neonatal observations done at birth were in range of normal." Dr Turner says "I also have no recollection of Luc's breathing being particularly laboured at birth. He was certainly mucousy but this is a very normal phenomenon." The Delivery/Neonatal Summary form which has been completed by Ms Summers records that Luc's first breath was at "birth, respiration was established at "10 secs" and no resuscitation measures were required.
The records indicate that by 10.30 pm Luc had had his first breastfeed. Mrs na Champassak says that "he did not feed that well, was not really interested, I did not think he was that robust, but put it down to him being exhausted by his labour as well."
It is the parents recollection that some time after 10.00 pm they had a further conversation with Ms Summers when they enquired what to expect overnight and during the next day. They say that at this time they also specifically asked when the paediatrician would see Luc and that she said the inspection would take place in the morning. At about 11.30 pm Luc was taken to the nursery so that his mother could rest. He was taken by registered nurse, Dorothy Newman. She describes Luc at this time as "a little mucousy and slightly grunty but not untoward, his extremities were bluish but centrally he was perfused well." Whilst in the nursery Luc was noted by registered nurse, Katrina Crichton Gill to have "a degree of tachypnoea of the newborn" which prompted her to carry out a set of post delivery observations. (Tachypnoea is defined as "unduly rapid breathing") The observations were recorded at 3.00 am on 8 March in these terms, Tachypnoea, R70, T36.8 contused face." At about this time Mrs na Champassak came to the nursery to breastfeed Luc. She says that Ms Newman told her that Luc's breathing was a bit laboured and that he should be seen by a paediatrician. The breastfeed at this time proceeded well, Ms Crichton-Gill recording it as "good rhythmical sucking-long feed" and Mrs na Champassak agreeing that "he breast fed better than after his birth." Ms Newman recollects that "at 6.30 he was fast asleep and comfortable. He was a little noisy with his breathing but was not tachypnoeic and it was not loud. His breathing was better than it had been when he first came to the nursery." Ms Newman also says, "I do recall saying to Amanda that we would be watching the grunting and assured her that it was common for babies to do this after birth." Ms Newman has recorded that at about 6.30 am Luc was "Sl grunty." At about that same time Mrs na Champassak collected Luc from the nursery and returned to her room with him. In her rounds that morning Dr Turner called on Mrs na Champassak at about 7.30 am. She acknowledges that she did not read the nurses overnight notes but says that Acting Nurse Unit Manager, Ms Rosemary Lai had told her that Luc "had been somewhat mucousy during the night." Ms na Champassak told Dr Turner that she was fine and reminded her that Luc needed to see a paediatrician. Dr Turner did not examine Luc at this time. She says that she requested a paediatric review at that stage. She describes her request in these terms, "I asked after my round that Dr Hallam be contacted as soon as possible and thought that I had communicated that to the midwives and I was somewhat surprised later in the day to find this had not been done."
Luc remained with his mother that morning. When Mr na Champaasak first saw his son that day (this was before 8.30 am) he noted that he was breathing "in an unusual rasping/grunting way, although I thought it was his cute way of breathing and said so to Amanda." Registered Nurse, Ms Christina Galloway commenced caring for Mrs na Champassak and Luc at 9.00 am. There is an entry at 10.20 am in the record indicating a breast feeding score for one side only as A1. At 10.20 am both sides are scored as A5. There is also the comment, "Enc to suck". Another entry at 12.00 noon says, "First bath." Of this event Ms Galloway says in her statement, "Luc's first bath was attended by Dad (Phil) around 12.00 midday, with her children watching. I attended Luc's length and head circumference and noted he had a contused face. Nil respiratory distress noted. No further intervention." Of that mornings breast feeding Mrs na Champassak says, "I did not think he was a robust feeder like my other children had been, but once again, I put this down to him being new and learning, and I was rusty." Mrs na Champassak makes this further comment, "He had been making some grunting noises for about 45 minutes after his bath". She says that subsequently, "Luc was lying in my lap and he nodded off to sleep." Then, "I wrapped Luc up and put him in his cot asleep on his back. I thought the bath had definitely relaxed him now……… This was approximately 2.00 pm."
Ms Galloway says that she reviewed Luc and his mother at about 1.30 pm. Mrs na Champassak reminded her that the paediatrician (Dr Elizabeth Hallam) had not yet seen the baby. Ms Galloway says that she then contacted Dr Hallam and informed her that she had two babies to review and stated that there was no urgency. Apparently Dr Hallam replied that she would attend after her clinic. Ms Galloway says that she advised Mrs na Champassak of this at about 2.00 pm. At this time she was sitting with Luc in a chair.
Ms Lai accompanied Dr Turner on her round on the morning of 8 March. She recalls Dr Turner telling her, after she had spoken to Mrs na Champassak, that Luc "Was mucousy overnight - please ask Dr Hallam to do her baby check today." Ms Lai says that she later passed this request on to Ms Galloway. Ms Lai further says that sometime between 9.30 and 10.30 am that morning she was asked by Mrs na Champassak to demonstrate wrapping Luc. Ms Lai describes Luc at this time in these terms, "He appeared normal, his face was contused from delivery, and I remarked on this to Amanda - reassured her that it would resolve in a few days. Luc's breathing was normal, colour normal, response to noise and muscle tone normal. Amanda and I discussed wrapping babies as I wrapped Luc in his bunny rug and passed him to Amanda."
The parents provided Dr Roy with 3 short videos taken shortly after Luc's birth. He says that they are consistent with a baby lacking vigour. He comments that it is not uncommon for a baby who is vigorous enough at birth to record a normal Apgar score to then regress to a more lethargic state and that this is not necessarily a matter for concern. However, it does raise as a possibility that any regression in Luc's case may have been an indicator of either a hypoxic challenge during labour or of a pethidine effect. Dr Roy agrees that one video does evidence some mild grunting breathing which in his view, if heard by Ms Summers, is inconsistent with her statement that Luc was breathing normally.
In his report Dr Roy makes these helpful comments upon abnormal respiration:
- "…..it is well recognised that minor degrees of tachypnoea or intermittent tachypnoea and grunting can occur as newborn babies clear their fetal lung fluid and establish adequate lung volumes." It is normal for these signs to settle within about an hour. It is not cause for a paediatrician to be called if they do not do so if the baby is otherwise normal. However, any such abnormalities still occurring nine hours after birth does warrant a paediatric examination.
- The diagnosis of respiratory distress is poorly defined. It requires the presence of at least two abnormal respiratory signs occurring simultaneously. Terms such as grunting, mucousy, laboured breathing and tachypnoea are all signs of abnormality. Of particular importance are signs of steadily worsening laboured and noisy breathing.
Minor degrees of grunting can be described as "cute" breathing noises, (the term used by Mr na Champassak). However, a severe grunt is readily recognisable as being abnormal, both by lay persons and health professionals because the babys breathing is clearly distressed.
Findings Upon Respiratory Distress
It is clear that from the outset Luc's breathing was to some degree compromised. This is acknowledged by Dr Turner who described it as "mucousy." It is confirmed by the video clip which Dr Roy says indicates mild grunting breathing. I accept that these signs were not sufficiently abnormal to require immediate paediatric involvement. However, they did, in my view, require close monitoring. Luc was in the Private's nursery for about seven hours to 6.30 am on 8 March. It is clear on the evidence that during this period signs of respiratory abnormality were persisting as acknowledged by both nurses Newman and Crichton-Gill, the former recording signs of tachypnoea at 3.00 am and the latter noting Luc's breathing at 6.30 am to be a "little noisy" (recorded as "Sl grunty") but better than previously. This evidence is, in my view, insufficient to permit a finding that Luc was suffering respiratory distress at this time so to satisfy the definition of this condition as described by Dr Roy. Nevertheless, it is clear that those signs of respiration compromise observed immediately after birth had not fully resolved within the subsequent 9.5 hours and their persistence, even if intermittent and not apparently worsening in degree, did warrant prompt paediatric attention and this is particularly so given the parents own concerns about their sons breathing and their repeated requests that a paediatrician attend him. It is pertinent for me to observe that Dr Turner had, at the time of her morning rounds, also assessed that a paediatric examination of Luc was required. This is a matter which I will return to in a moment.
I have noted that Mr na Champassak observed Luc's breathing early in the morning to be "rasping/grunting" and his wife noted "grunting noises for about 45 minutes" after his bath at about noon. However, in mid-morning Ms Lai has described Luc's breathing as "normal" and Ms Galloway, at the time of the noon bathing has stated "Nil respiratory distress noted." These observations are, upon one view, conflicting. However, this is not necessarily so. Instead each may be accurate and simply reflect the fact that Luc's signs of abnormal respiration were intermittent and/or not always readily apparent. In my opinion it is not necessary for me to resolve whether any inconsistency exists. This is so because, as I have already said, Luc's respiratory history up to 6.30 that morning justified paediatric intervention and those subsequent observations made by the parents and nursing staff did not change the situation.
The Cause of Luc's Death?
I have set out in the introduction to these findings the opinion of forensic pathologist, Dr Ritchey that Luc died from acute bronco-pneumonia.
Dr Williams makes these specific comments upon the cause of death:
"Luc died of neonatal aspiration pneumonia caused by Enterococcus faecalis and Staphylococcus aureus. These bacteria were acquired by Luc in the birth canal. These bacteria colonise in the mothers genital tract and can be asymptomatic. The infection of the baby took several hours to manifest. There were symptoms and signs that were suggestive of illness. The infection escalated over the ensuing 17 to 19 hours and caused death in sleep. On balance of probability had the baby had a proper medical examination by a competent doctor, the signs and symptoms of the infection would have been noted."
Dr Roy, in contrast, does not accept that Luc's death should be classified as being attributable to acute bronco-pneumonia. He specifically rejects Dr Williams view that pneumonia was caused by bacteria. Rather, it is his concluding view that Luc's cause of death should be stated as Sudden Unexpected Death in Infancy with the main contributing factor being pneumonitis from inhaled squamous epithelial cells. He also identifies several other possible contributing factors. I consider Dr Roys consideration of this issue to be particularly comprehensive and insightful. It is helpful for me to set it out in full:
"Why then did Luc die? It is clear from the pathologist's report that there was inflammation in the lungs as evidenced by the significant presence of leukocytes in the alveoli; this inflammation is most likely as he surmises caused from the aspiration of epithelial (squamous) cells. The only likely origin of such cells is from inhaled amniotic fluid; generally it takes an abnormally strong inhalation in utero or during birth for these cells to reach down into the alveoli, and such a breath is generally only taken during times of acute fetal distress; it is not clear when this might have occurred in Luc's case, although the difficulty with the labour as he was in a posterior position may have caused distress that was undetected. A CTG recording might have helped to illuminate this question. Dr Williams states that the "cord was around his body" although I cannot find where this is documented; if this is so, then cord compression during labour may have caused such fetal distress and thus a large in utero gasp and inhalation of amniotic fluid with squamous epithelial cells.
Importantly, I disagree that this was pneumonia caused by bacteria. This is based on the following -
No bacteria were seen on microscopy (an overwhelming pneumonia would have had clearly visible bacteria, especially as neither Luc nor Amanda had antibiotics at any stage). One should qualify this by pointing out that there is no statement that a Gram stain was performed on the lung tissue specimen.
No bacteria were grown from swabs of the cut lung surfaces at autopsy.
The growth of the two organisms Staphylococcus aureus and Enterococcus faecalis - is almost certainly because of a contaminated specimen taken from the umbilical venous catheter inserted without antiseptic precautions during resuscitation in Royal Hobart Hospital:
- These organisms could readily have been on Luc's abdominal surface around the cord.
- An overwhelming pneumonia would have been caused by a single organism, not two.
- The growth of two organisms strongly suggests contamination of the specimen.
- It would be highly unusual for either of these organisms to cause pneumonia as early as this, especially as there was no evidence of infection before birth (but see my later comment on lack of microscopic examination of the placenta).
- Had the pneumonia been due to an overwhelming bacterial infection, Luc would have clearly been extremely unwell, which appears not to have been the case.
- There was no haematological supportive evidence of infection:
- The CRP was normal.
- The neutrophil component of the white cell count was normal.
- Dr de Paoli noted that on admission to the Royal Hobart Hospital Neonatal Unit Luc was "Easy to ventilate with compliant lungs". This would not be the case with extensive pneumonia, in which one would expect stiff lungs with poor compliance.
There is no doubt that the pneumonitis caused by inhalation was a contributing factor, probably the most significant contributing factor to Luc's death; yet it was insufficient to cause more than mild signs affecting the respiratory system, insufficient to say he had actual "respiratory distress". (I use the term "pneumonitis" advisedly, in that the term "pneumonia" for some authorities implies a bacterial origin, which I do not believe to be the case here. "Pneumonitis" implies inflammation of the lungs, of which bacterial infection is only one of several causes). I believe that Luc therefore falls into the category "Sudden Unexpected Death in Infancy" (SUDI); the report from the Royal College of Pathologists and the Royal College of Paediatrics and Child Health provides a classification of SUDI and I attach this Appendix 2. I believe Luc falls into Category II, probably 1113, in that the pneumonitis almost certainly contributed to his ill health and contributed to his death. I note that Luc's parents understand that SUDI (or SIDS) does not occur in newborn babies; unfortunately it does occur rarely at this time in life, although they are correct in their view that it is much more likely after several weeks or months of life.
Were there additional contributing factors to Luc's death?
There are features in Luc's measurements and in his autopsy findings that support a finding of him being phenotypically an infant of a diabetic mother (IDM). While Amanda had been shown not to be diabetic at 30 weeks' gestation, there is a strong family history of diabetes and a woman who has a baby with features of an IDM may be considered to be "pre-diabetic". She herself is not diabetic, but the infant may behave like an IDM. The features in Luc that support this include:
His birth weith of 3920g (between the 75 and 99 centiles, length of 54.2cm (90 centile), but head circumference of 36 cm (50 centile) i.e. disproportionate growth of weight and head..
The abnormally high weights of some of his internal organs, especially heart 26g (expected 19.1 +/- 2.8g), liver 192g (121.3 +/- 39.2g), kidneys 40g (26.1 +/- 4.9g) and lungs 70g (42.6 +/- 14.9g), although there may be different explanations for the increased lung weights (see below). Of note is that the brain is within the normal range at 392g (expected 337 +/- 91g). This "sparing" of excess brain growth is a feature of IDMs; the brain/liver weight ratio (2) is suggestive of macrosomia.
The suggestion of Luc being an IDM is relevant for a number of reasons:
IDMs are prone to increased lung fluid retention, which may have been a contributing factor to his respiratory signs.
IDMs are more prone to hypoxic-ischaemic problems in labour, which might explain his inhalation of squamous epithelial cells.
It is a rare but well recognised complication of IDMs that if they have borderline respiratory problems culminating in marginal oxygen saturation they can quickly develop pulmonary hypertension (previously known as "Persistent Fetal Circulation") which can lead to a rapid downhill course.
IDMs often do not feed well in the first few days of life.
There may have been additional reasons for Luc having retained lung fluid as a contributing factor to his respiratory signs; as discussed earlier the induction of labour may have contributed to this, and some would claim that a short 2nd stage of labour (which Amanda had) can also contribute. The increased weight of the lungs at autopsy may be a reflection of retained lung fluid, but may also reflect the inflammatory process. Histopathology of the lungs is unlikely to recognise retained lung fluid.
Although Luc was in good condition at birth the aspiration of squamous epithelial cells is suggestive that he was exposed to hypoxia-ischaemia at some stage in the labour. If this is the case then he may not have had optimal respiratory drive and reflexes to deal with the respiratory problems he faced. Babies following hypoxic-ischaemic exposure are also more prone to pulmonary hypertension.
There is also the possible role of residual levels of pethidine or its metabolites in Luc's blood or brain tissue, the effect being potentially to suppress respiratory drive and reflexes.
In summary I believe Luc na Champassak's death should be classified as a Sudden Unexpected Death in Infancy with the main contributing factor being pneumonitis from inhaled squamous epithelial cells. Other potential (but unproven) contributing factors include :
the possibility that he exhibited features of an infant of a diabetic mother
he may have been exposed to hypoxia-ischaemia in labour
he may have had some retained fetal lung fluid
he may have developed pulmonary hypertension
his breathing may have been compromised by the effects of pethidine and its metabolites
I believe that any one of the contributing factors on its own was insufficient to cause Luc's death and it is the tragic combination of a number or all of the factors coming together that caused his death."
Dr Ritchey was invited to comment upon Dr Roy's views upon the cause of death. He has responded in these terms; "I have had a chance to review Dr Roy's report and find it to be thorough and well documented. His criticisms (at least of my role) are well taken and I certainly don't disagree with him on any particular point including his interpretation regarding the cause of young Luc's death."
In a supplemental report Dr Roy has made these further comments; "With respect to the question of whether the bronchopneumonia seen by the pathologist was bacterial, I remain sceptical that this was so; I have already outlined my reasons for this in my original report; in addition, at autopsy there were Gram stains of lung swabs even though the lung tissue itself did not have Gram stains. One set of lung swabs showed no leucocytes, epithelial cells++, but no organisms were seen. The second lung swab on Gram stain showed leucocytes+++ and again no organisms were seen. If a baby dies from overwhelming bacterial pneumonia, it is not conceivable to me that there would be many leucocytes but no organisms visible on Gram stain. This is not to deny the presence of bronchopneumonia, but emphasise that the pneumonia (I have termed it pneumonitis) was one from aspiration of amniotic fluid debris rather than of bacterial origin."
I am satisfied, for the reasons articulated by Dr Roy and accepted by Dr Ritchey, that Luc's death should be classified as being attributable to Sudden Unexpected Death in Infancy with the principal contributing factor being pneumonitis from inhaled squamous epithelial cells. Specifically, I reject the view that the pneumonitis was bacterial in origin. I accept that it is probable that those other five factors identified by Dr Roy as being potential contributory factors may have played a role in the death, either individually or collectively, but the evidence is insufficient for me to make a positive finding to this effect.
The Adequacy of Luc's Care
Issues Surrounding Paediatric Intervention
I have, for the reasons set out above, determined that Luc's respiratory condition required paediatric examination and this had become evident, at least by the early morning of 8 March. At about 7.30 that morning Dr Turner directed that a paediatrician be asked to attend Luc but this had not occurred before his death almost nine hours later. How could this come to be?
As I have said above, Dr Turner was aware at the time of her morning round that Luc had been "mucousy" overnight and she directed Ms Lai to have Dr Hallam examine Luc "as soon as possible." It is clear that Ms Lai did not detect any urgency in the direction, she interpreting Dr Turner to have meant that Dr Hallam should attend to examine Luc "today." She thus asked Ms Galloway to make the request of Dr Hallam but did not do this until after Ms Galloway began her shift at 9.00 am. It was only at about 2.00 pm, after Mrs na Champassak queried where the paediatrician was, that Ms Galloway then made contact with Dr Hallam. She apparently told Dr Hallam that there was no urgency and that it would suffice for a routine newborn assessment to be performed later in the day. Accordingly, Dr Hallam proceeded with an outpatient clinic with the intention of calling to see Luc when she finished at about 5.00 pm. Dr Turner has since acknowledged that, "In hindsight, given the concerns raised particularly by the parents, I should have rung Liz Hallam myself that morning and asked her to come and see the baby earlier than before the end of the day."
When Dr Turner determined that a paediatric examination of Luc was required "as soon as possible" and not just at some time during that day, it was incumbent upon her to make this clear to Ms Lai and further to make it clear that the examination required of Luc was not the normal newborn assessment but rather was an examination made necessary by his persisting, if intermittent respiratory abnormalities upon a background of parental concern. Had she done this one postulates that Ms Lai would herself have made immediate contact with Dr Hallam and impressed upon her that some immediacy attached to the need for Luc's examination. The failure by Dr Turner to clearly communicate her instructions to Ms Lai leads me to support a recommended improvement made by Dr Roy for the Private to review its processes for making referrals to paediatricians so that communication breakdowns of this nature are eliminated. I will refer to this again later.
The next issue for me to consider is whether a prompt paediatric examination would have averted Luc's death?
It is my view, that a thorough paediatric examination of Luc undertaken at least by mid-morning on 8 March coupled with a consideration of the documentation and the input of his parents would, in the very least have alerted the paediatrician to the likelihood that his respiratory system was compromised and that it would be appropriate for testing to be done for infection and for antibiotic treatment to be commenced. It would have also been appropriate for a level of respiratory support to have been put in place and for Luc's close monitoring in an intensive care setting, either at the Private or, perhaps more appropriately, in the RHHs Neonatal Intensive Care Unit.
I have already found that Luc's pneumonitis was not bacterial in origin. As a consequence it is unlikely that the early administration of antibiotics would have altered the outcome. Would Luc's death have been avoided by him being transferred to a facility equipped to provide close monitoring along with respiratory support? The evidence does not permit me to answer this question with any degree of certainty. Nevertheless, I am able to find that Luc's chances of survival would, in my opinion have been significantly enhanced had those steps been taken.
Dr Roy has expressed the view that the observation of Luc, prior to his birth was "inadequate" because of the failure to maintain continuous monitoring of a labour augmented by syntocinon. He points out that the Guidelines of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists prescribes such monitoring to be standard practice. He says that this is relevant in Luc's case because had such monitoring been in place it may have provided "evidence of fetal distress in labour that might have caused him to gasp and inhale amniotic fluid with squamous epithelial cells."
I am informed by the Private that it was not its practice at the time of Luc's birth for it to maintain continuous foetal monitoring of a syntocinon augmented labour unless ordered by the patients obstetrician. However, I am further informed that the Private has, since Luc's death, varied its policy so that all labours involving syntocinon are now to have continuous foetal monitoring. This is a welcome change. Had this policy been in place at the time of Mrs na Champassak's labour it may have helped to explain Luc's subsequent respiratory abnormalities and resulted in his closer monitoring with respiratory support.
The Private accepts that pulse oximetry was not performed on Luc, describing this as "an oversight." On this subject Dr De Paoli, the staff specialist Neonatologist at the RHH makes this comment (with which Dr Roy agrees):
"There is no record of the use of pulse oximetry (a means of assessing oxygenation) at any stage. It would be considered normal practice to use pulse oximetry as a means of assessing oxygenation, and possible need for supplementary oxygen therapy, in any newborn with respiratory distress."
As I have said earlier, the evidence is not sufficient to make a finding that Luc was suffering respiratory distress within the definition stated by Dr Roy. Nevertheless, there were signs during the night recorded at both 3.00 am and 6.30 am indicating some respiratory abnormality which, in my view, warranted close monitoring including the use of pulse oximetry. It is not possible to say whether the use of pulse oximetry would have brought about a different outcome but the failure to use it did, in my view, mean that information, vital to the state of Luc's respiratory function was not available to those caring for him.
As to the regularity of monitoring post birth, Dr Roy makes these observations, "It is standard practice elsewhere (but not necessarily universal) that frequent observations are taken after birth until the baby is stable: eg one private hospital in Melbourne states half hourly observations for at least two hours. If this was done at Hobart Private Hospital, it is not documented, and should have been done and documented. I see this as a systemic issue, not a personal one. Hobart Private Hospitals policy "Immediate Care of Infant at Birth" includes "Infants observations (temperature, Apex beat, respiration and colour) should be assessed and recorded on nursery notes until stable with appropriate nursing action taken to correct any abnormalities". This policy is not specific on the frequency of observations which is a shortcoming of the policy."
As I have already stated there were early signs that Luc's breathing was compromised and this persisted during the night, albeit intermittently. In these circumstances it could not be said, in my opinion, that Luc's condition was "stable" thus justifying the cessation of half hourly observations as required by the Privates then existing policy which provided for "half hourly observations on the newborn until stable." Rather, the situation required half hourly observations of Luc to be maintained during the night and for those observations to be documented. Had this been done, along with ongoing pulse oximetry, a clearer picture of Luc's condition would have presented itself in the morning of 8 March and may have led to a more immediate response on the part of the midwives and Dr Turner.
I am informed that since Luc's death the Private has amended its policy to now provide for "half hourly observations on the newborn for four hours and then until all observations are within normal limits." This is an improvement. However, it behoves the Private to ensure that it has sufficient staff on duty to enable its policy to be fully complied with and that its staff, not only comply with the policy, but that all their observations are fully documented.
Luc was declared deceased at the RHH at 4.20 pm on 8 March 2007. He was aged one day.
I am satisfied that Luc's death should be classified as Sudden Unexpected Death in Infancy with pneumonitis from inhaled epithelial cells being the main contributing factor. This classification is, in my view, appropriate because the evidence is not sufficient for me to find that the pneumonitis provides by itself a complete and sufficient cause of death.
At, or shortly after his birth, Luc had signs of respiratory compromise. Those signs had not completely resolved during the night prior to his death and necessitated Luc being closely monitored during that night. Such monitoring should have included fully documented, half hourly observations with pulse oximetry. Had this occurred, it is probable, in my view, that the midwifery staff and Dr Turner would have better appreciated that Luc had ongoing respiratory difficulties which warranted prompt intervention.
At the time of her morning round on 8 March Dr Turner was of the view that Luc should have a paediatric examination "as soon as possible." This was appropriate given Luc's respiratory history coupled with the parents concerns. However, regrettably such examination had not taken place before Luc's death. This came about because Dr Turner failed to communicate to nursing staff that Luc required a prompt examination because of his respiratory abnormalities coupled with parental concern and that the examination was not the normal newborn assessment.
I am not able to positively find that Luc's death would have been avoided if he had been more closely monitored (including foetal monitoring) during his short life. Nor am I able to positively find that the outcome would have been different if a paediatric examination had been undertaken in the morning of 8 March. Nevertheless, I am of the view that a level of monitoring which complied with the Privates then existing policy coupled with a prompt paediatric examination would probably have confirmed that Luc was suffering a respiratory abnormality which required respiratory support and monitoring in an intensive care setting. These steps, if taken, would have significantly enhanced Luc's prospects of survival.
How could care at the Private be improved?
In his report Dr Roy identified the following areas where the Private could improve its standards of infant care:
1. Put in place a clear protocol for the observation of babies for the first 2-4 hours after birth with observations continuing until they are normal and the baby is stable. Re-appearance of any abnormal signs require regular observations to be re-instated.
2. Adopt clear models of care for the examination of new born babies. They need to be in place. Ie it must be clear as to whether the physical examination is to be performed by the obstetrician, the midwifery staff, or a paediatrician.
3. The process for referrals to paediatricians needs to be clarified. There must be a clear path stating whether the referral is acute or routine. It is preferable, but not mandatory, that all referrals should be from the obstetrician to the paediatrician personally but all acute referrals must be by personal contact.
4. A review of standards of documentation is required with the development, implementation and regular audit of clear guidelines for documentation."
I acknowledge that the Private conducted its own Root Cause Analysis into the circumstances of Luc's death and has already implemented some improvements to its practices including some of those identified by Dr Roy. I note too that it has now stipulated that continuous foetal monitoring be undertaken for all syntocinon augmented labours. I support each of those improvements identified by Dr Roy and recommend that they be fully adopted by the Private if it has not already done so.
I conclude by extending my condolences to Luc's family for their tragic loss.
Dated the 1st day of February 2010.