Record of Investigation Into Death

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler, Coroner, having investigated the death of

Xavier MURRAY

Find That :

Xavier Murray ('Xavier') was born at the Calvary Hospital ('Calvary') in Hobart on 2 May 2008 His parents are Ian Robert Murray and Kristen Maree Murray.

Xavier died on 5 May 2008 at the Royal Hobart Hospital ('the Royal') in Hobart aged 3 days.

I find that Xavier died as a result of hypoxic/ischaemic brain damage due to birth asphyxia.

At the time of Xavier's death he was in the care of medical practitioners at the Royal.

Introduction

In August 2007 Mrs Murray became pregnant with twins. Her treating obstetrician and gynaecologist was Dr Peter Reynolds. Her paediatrician was Dr Mark Pascoe. The pregnancy proceeded uneventfully until 37 weeks gestation when Dr Reynolds became concerned by an apparent worsening discrepancy between the estimated foetal weights of the two twins. A decision was then taken for Mrs Murray to be admitted to Calvary and for her labour to be induced.

At 2.24 pm on 2 May 2008 the first twin was successfully delivered. He was named Joe. He was a healthy babe. Eighteen minutes later his brother Xavier was born. He was described by Dr Reynolds as "pale and floppy immediately on delivery." Despite emergency measures Xavier remained critically unwell. He was transferred to the Neonatal and Paediatric Intensive Care Unit at the Royal but died on 5 May 2008.

Xavier's death has been the subject of a coronial investigation without inquest. That investigation has been greatly assisted by evidence provided by Dr Neil Roy, a consultant neonatal paediatrician and by Dr John Regan, an experienced obstetrician and gynaecologist based at the Monash Medical Centre in Victoria.

Summary of Events Leading to Xavier's Transfer to the Royal

In his report Dr Roy provides a comprehensive and accurate summary of the clinical events. It's convenient for me to repeat it here. It follows:

Admission at the Royal

Xavier was received at the Royal at 5:00pm on 2 May 2009. Dr Antonio DePaoli is the Royal's Staff Specialist Neonatologist. He describes Xavier's presentation and initial treatment as follows:

• "Neurological: flaccid, no gag, no suck, pupils dilated with no  reaction to light, absent reflexes.

•  Respiration: ventilated 30/6 in 100% oxygen initially, gasping respirations, oxygen saturations were initially unrecordable because of poor circulation.

• Cardiovascular: poor perfusion (grossly prolonged capillary refill), initial blood pressure (invasive and non-invasive) greater than 40 mmHg, dopamine commenced.

• Biochemistry: 1st blood gas (umbilical venous sample) at RHH (1st since cord sample at delivery at Calvary): pH 6.4, pCO2 113, HCO3 7.8, Base deficit -39, lactate 16. This blood gas demonstrates an extremely severe mixed acidosis and represents a major deterioration in comparison to the cord blood gas taken soon after birth. The blood gas result is consistent with a severe hypoxic-ischaemic insult. Sodium bicarbonate corrections were administered.

• Haematology: FFP and vitamin K were given for severe coagulopathy.

• Commenced antibiotics."

By the following day, Xavier was recorded to have multi-organ failure which Dr DePaoli noted was consistent with 'the severity of the global hypoxic ischaemic insult.' On 5 May 2009 Dr DePaoli made the following observations of Xavier's condition:

• "Ongoing severe multi-organ“Ongoing severe multi-organ failure:

• • • Worsening encephalopathy (severe) now with intractable seizures requiring multiple anticonvulsants.

    • Persisting supplemental oxygen requirement (40%) and ventilator dependent.

    • Persisting dependence on maximal inotropic support to maintain blood pressure.

    • Worsening encephalopathy (severe) now with intractable seizures requiring multiple anticonvulsants.

    • Persisting severe coagulopathy, oliguria and thrombocytopenia.”

At this time the decision was taken by Xavier's parents, after discussion with the treating physicians, to withdraw intensive care support. Xavier died at 4:15pm.

Post-Mortem Examination

A post-mortem examination was undertaken by State Forensic Pathologist, Dr Christopher Lawrence. In his report he makes these observations:

I cannot identify a definite cause of the low Apgar score at one minute."

In Dr Lawrence's opinion the cause of Xavier's death was hypoxic/ischaemic brain damage due to birth asphyxia.

Issues for Consideration

The circumstances of Xavier's death have given rise to several specific issues which, in my view required particular consideration. They are:

1. Is there a clinical explanation for the birth asphyxia?

2. Was there a delay in effective resuscitation and if so did it alter the outcome?

3. Do twin deliveries using Ventouse extraction constitute a high risk delivery requiring the presence of a paediatrician at the time of the delivery to provide effective neonatal resuscitation?

I propose to deal with each of these matters in turn.

Explanation for the Birth Asphyxia?

Dr Lawrence has included in his report these comments upon birth asphyxia and its possible causes:

"Birth asphyxia occurs when a baby does not receive enough oxygen before, during or just after birth. There are many reasons that birth asphyxia may occur.

Dr Lawrence has stated that he was unable, at autopsy, to identify the cause of Xavier's birth asphyxia.

Dr Roy accepts Dr Lawrence's definition of birth asphyxia and his list of possible reasons. In his report he comprehensively reviews the possible explanations for Xavier's asphyxia but concludes:

"In summary on this question, I too find it difficult to identify a definite cause for Xavier's birth asphyxia; because fetal hypoxia/ischaemia is the most common explanation for this situation it must still be considered the most likely, despite the lack of evidence from intra-partum monitoring and cord pH, but the cord lactate tends to support some degree of hypoxia. The possibility of the delivery being more traumatic than was evident or that there may have been cord compression or a placental malfunction are possible explanations, but there is little evidence to support these. I also believe that a neuromuscular cause should be considered."

He makes this further comment:

"There are a number of possible explanations as to why his birth asphyxia worsened following delivery, mainly questions around the adequacy of his lung ventilation, but also the possibility that persisting pulmonary hypertension may have played a significant role in his failure to respond to resuscitation."

Similarly, Dr Regan has been unable to provide a likely explanation for Xavier's birth asphyxia. He comments:

"……there does not appear to be a clinical explanation for Xavier Murray's birth asphyxia. There were no signs either antenatally or intrapartum of any problems with Xavier, and Dr Reynolds' management of Mrs. Murray's labour cannot be faulted. Adequate foetal monitoring occurred, and the decision to take Mrs Murray to theatre for a trial of Ventouse and query caesarean section, was appropriate management.

The delivery of both twins was expeditious, with an 18 minute delay between the birth of the first and second twin being a reasonable time frame. The deliveries of the first and second twins appear to be identical, with both presenting in an occipito-posterior position, and both being delivered with a rotational Ventouse delivery.

We do encounter second twins who are born in unexpectedly poor condition, with no clear understanding as to why this does occur. There are occasions when there will be a degree of placental separation which will lead to the poor condition, and for that reason it is wise that there is no delay between the birth of the first and the second twin. In the case of Mrs. Murray, an 18 minute delay between the birth of the first and second twin is a very reasonable time for both twins to be born."

Despite their detailed consideration of the issue neither the State Forensic Pathologist nor Drs Roy and Regan have been able to establish a likely explanation for Xavier's birth asphyxia. This leaves me in the position where, regrettably, I am unable to make a positive finding on this subject.

Was there a delay in effective resuscitation and if so, did it alter the outcome?

It is apparent on the evidence that there was no delay in commencement of the initial resuscitation with tactile stimulation followed by Vitamin K injection and then bag and mask ventilation. All of these steps were appropriate and timely. A real issue, as Dr Roy identifies, is whether there was a delay in proceeding from basic resuscitation to advanced resuscitation with intubation or possibly intravenous cannulation. On this subject Dr Roy makes these observations:

"Xavier had shown some response to his initial resuscitation and had been noted to make breathing efforts between 4 and 8 minutes of age. However if there was no further breathing effort beyond 8 minutes of age, it would appear that delaying until 18 minutes of age to proceed to endotracheal intubation is longer than one would have anticipated; this may have been delayed in the hope that endotracheal intubation was not required because of inexperience of the resuscitators, but I have no evidence either way to suggest whether Dr Reynolds feels he has good experience in neonatal intubation. One would not necessarily expect him to have expertise in this, and he might well have delayed on these grounds."

Dr Roy then concludes; "Earlier endotracheal intubation may well have improved the outcome."

A related issue is the adequacy of the resuscitation undertaken. Dr Roy says that it is pertinent to make the observation that "the pressure required to effect the first inflation of the lungs can sometimes be extremely high, and sometimes only an experienced operator can achieve this." He then offers this opinion:

"While every health professional who attends deliveries is expected to be able to initiate bag and mask ventilation, nevertheless obstetricians rarely have the need to apply this technique and may have difficulty in achieving adequate lung inflation, especially in difficult cases, and I am sympathetic to Dr Reynold's predicament. Problems that arise with this technique include-

1. Incomplete seal of the mask around the baby's face,

2. Suboptimal opening of the upper airway,

3. Inadequate pressure and/or flow for inflation of the lungs and

4.  Failure of the equipment.

There is no direct evidence from the documents provided that any of the above applied in this instance; however because of the lack of response from Xavier to the bag and mask ventilation, there is a strong possibility that there was inadequate lung inflation by this technique."

Dr Roy concludes;

" It is likely that we will never be 100% sure that the resuscitation performed was as good as it might have been, but the fact that it was performed by health professionals who would not normally be expected to have the most expertise in this procedure, it is reasonable to believe that the outcome might have been improved had there been a more experienced resuscitator (i.e. a paediatrician) there earlier. This possible difference in outcome is by no means certain, because we do not fully understand why Xavier appeared as he did at birth."

Dr Regan introduces his comments on this subject by saying that a neonatologist is best qualified to provide an expert opinion upon it. Nevertheless, he makes this general observation; "I can comment that a delay in effective resuscitation will alter the outcome of a compromised neonate, and adequate active resuscitation as soon as possible will give a compromised neonate the best possible prognosis."

The foregoing leads me to conclude that the initial steps taken to resuscitate Xavier were both prompt and appropriate. However, it is apparent that Xavier's response to the bag and mask ventilation was less than optimal although the reason for this has not been discernible. These circumstances, in my opinion, required a speedy resort to endotracheal intubation. This was not attempted until Xavier was 18 minutes of age and was not achieved until 2 minutes later. I accept the view of Dr Roy that this delay was "longer than one would have anticipated" and thereby reduced the prospect of a more favourable outcome. I also accept that endotracheal intubation, if its effectiveness is to be maximised, requires the attendance of a health practitioner experienced in the technique such as a paediatrician.

Do twin deliveries using Ventouse extraction constitute a high risk delivery requiring the presence of a paediatrician at the time of the delivery to provide effective neonatal resuscitation?

Dr Roy notes that while all deliveries using the Ventouse extraction method involve increased risk, it does not necessarily follow that paediatric assistance would be called for in every case where this procedure is used. Dr Roy also notes that the delivery of twins itself involves significant risk, and his view is that for some obstetricians standard practice would include requiring the presence of a paediatrician due to the risk to the second twin. Specific to the circumstances prevailing at the time of Xavier's birth Dr Roy says:

"Twin delivery using Ventouse extraction would constitute a significantly higher degree of risk, and especially if it is being done in the operating theatre because of an occipito-posterior position with a view to proceeding rapidly to caesarean section should this become necessary. The combination of twins, Ventouse extraction and delivery in theatre with a potential view to caesarean section in my opinion does constitute a high risk delivery requiring the presence of a paediatrician."

And;

"In hospitals where it is known that specialist paediatricians are on-site and available within a minute or two, it might be acceptable practice to allow some degree of risk in a delivery before expecting a paediatrician to be in the room; for instance this situation might pertain in the private section of The Royal Hobart Hospital. However it is not acceptable practice for high risk deliveries to be occurring without the presence of a paediatrician when the paediatrician may be quite some time away, as was the case with Xavier's delivery. In this situation the delay in obtaining a paediatrician was aggravated by traffic delays, including rainy weather and possibly an accident; this only goes to emphasise the need to have a paediatrician on-site preferably present in a situation of this level of risk."

Dr Regan comments similarly saying:

"All twin pregnancies should be considered a high risk pregnancy, and it is my opinion and common practice to have a paediatrician present at the time of a twin delivery. In the case of Mrs. Murray, Dr Reynolds decided to take her to theatre for a trial of Ventouse delivery or a possible caesarean section, and it would have been a reasonable expectation for a paediatrician to be present at the time of the birth of both twins."

Dr Pascoe seems in accord with these opinions, he stating; "It would be usual practice for an obstetrician to request that a paediatrician be present during multiple births and for all caesarean sections."

It is relevant to note that at the time of Xavier's birth Calvary did not have in place a local policy relating to multiple births. However, it has since formulated and adopted a "Multiple Pregnancy" policy which includes a provision which requires that the obstetrician, anaesthetist and paediatrician and/or medical officer be informed of the patient's admission during the first stage of labour. It also requires, during the second stage, that the paediatrician and the anaesthetist "must be in the hospital."

I am satisfied, accepting the opinions of both Drs Roy and Regan, that the circumstances of Xavier's birth did require the attendance of a paediatrician, specifically Dr Pascoe.

The Absence of Dr Pascoe and Consequential Findings

The evidence indicates the following sequence of events as it relates to Dr Pascoe:

• On the morning of 2 May Dr Reynolds notified Dr Pascoe of the twins' expected births "within the next 24 hours." At 10.00 am that day Dr Pascoe saw Mrs Murray at Calvary. The nurse's note records that Mrs Murray was told that Dr Pascoe would see her "post delivery."
• At 1.30 pm Dr Reynolds notified Dr Pascoe that Mrs Murray was being transferred to theatre in readiness for the twins' delivery. At this time Dr Pascoe was "busy consulting with patients" in his rooms at St John's Hospital in South Hobart. He informed Dr Reynolds that he could attend in 10 minutes if "there were any concerns."
• It was Dr Reynold's expectation that Dr Pascoe would attend at Calvary as soon as he notified him. However, when he was informed that Dr Pascoe only intended attending if required, he decided to proceed with the deliveries. He did so, he says, because he believed that his "own neonatal resuscitation abilities were sufficient to sustain adequately an infant for this (10 minute) period or longer."
• Xavier was born at 2.42 pm.
• At 2.44 pm Registered Nurse Sandra Morris 'phoned Dr Pascoe and requested his attendance at Calvary. She told him that Xavier was "dusky and slow to breathe."
• Nursing staff made two further calls to Dr Pascoe urgently requesting his attendance. He informed them that he was "delayed by traffic."
• Dr Pascoe attempted to arrange by telephone to have another paediatrician attend at Calvary. Contact was made with Dr Michelle Williams who quickly travelled from the Royal to Calvary but arrived a little after Dr Pascoe.
• It is the evidence of Nurses Parker, Newman and Carr that Dr Pascoe arrived at the Calvary theatre at 3.20 pm or thereabouts. I accept their evidence and find that Dr Pascoe did arrive at about 3.20 pm, that is some 36 minutes after the first call made by Nurse Morris requesting his attendance.

As I have found, the delivery of Mrs Murray's twins was sufficiently high risk to require the presence of a paediatrician. Dr Pascoe, as Mrs Murray's paediatrician did not meet that requirement because he was not present for the delivery of either Joe or Xavier. Further, it was not in my view good practice for Dr Pascoe to place himself in a position where he could not attend an emergency inside 10 minutes and where circumstances beyond his control could significantly extend that period as in fact occurred in this instance. Rather, it is my view that Dr Pascoe's obligation to Mrs Murray and to Xavier required him, as soon as he was notified by Dr Reynolds that Mrs Murray was being taken to theatre, to either have promptly attended himself or at least monitored the situation with the assistance of theatre staff so he was in a position to attend immediately upon the first twin's birth becoming imminent. This would have necessitated him remaining on the Calvary premises.

I am not able to find that Xavier's death would have been avoided if Dr Pascoe had been available at the time of his delivery to manage his treatment including his resuscitation. After all, it has not been possible to establish the cause of Xavier's poor presentation at birth. Nevertheless, I can find that his prospects of survival would have been improved if Dr Pascoe had been available to carry out his resuscitation.

Findings & Comments : 

I am satisfied that there has been a thorough and detailed investigation into Xavier's death and that there are no suspicious circumstances.

I accept the opinion of Dr Lawrence, and find that Xavier died as a result of hypoxic/ischaemic brain damage due to birth asphyxia.

For the reasons explained above I am unable to make any finding upon the cause of Xavier's birth asphyxia. Also for the reasons explained I am satisfied that the delivery of Mrs Murray's twins required the attendance of a paediatrician. Dr Pascoe's regrettable absence meant that Xavier was denied his resuscitative expertise for the first 38 minutes or thereabouts of his life. However, I am unable to make a positive finding that Xavier would have survived if Dr Pascoe had been present at this critical time.

Calvary has, since Xavier's death, put in place a "Multiple Pregnancy" policy which requires the treating paediatrician to be on its premises by the second stage of labour and hence available to promptly attend at delivery. This policy will, if followed, avoid delay in securing paediatric assistance for multiple births thus reducing the prospect of a similar infant tragedy occurring in the future.

I conclude by extending my sincere condolences to Xavier's parents and family.

DATED : Monday 29 August 2011 at Hobart in the State of Tasmania

Rod Chandler
CORONER