Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Olivia McTaggart, Coroner, having investigated the death of 'Baby W'. 

These findings have been partially de-identified in relation to the name of the deceased by direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995

I Find That:

(a) The identity of the deceased is  ‘Baby W’

(b) The Infant died in the circumstances described below;

(c)  The Infantdied as a result of aspiration pneumonia complicating large volume aspiration of amniotic fluid and meconium; and

(d) The Infant died November 2011 at the North West Private Hospital in Burnie, Tasmania;

(e) The Infant was born in Burnie, Tasmania on November 2011 and was aged one day;

(f) No other person contributed to the cause of “Baby W” death.

Circumstances Surrounding the Death:

The Infant was the first child of Ms W and Mr DThey reside in, Queenstown. Ms W became pregnant with  ‘Baby W’ in February 2011.

From November 2011 Ms W had been staying at an on-site accommodation unit in the grounds of the North West Regional Hospital, Burnie, for the purpose of antenatal, perinatal and some postnatal care for her first pregnancy. Ms W had received antenatal care until this point from Dr Foot (obstetrician/gynaecologist at the North West Private Hospital) and from midwives in Queenstown.  The pregnancy had been uncomplicated.

At9.30am November 2011 Ms W spontaneously went into labour and presented to the North West Private Hospital (NWPH). This was gestation of 40 weeks plus six days.  At this time a cardiotocograph (CTG) was taken to assess the unborn baby’s heart rate and the effects of uterine contraction.  Ms W had an internal examination which revealed that her cervix was about 1 centimetre dilated.  After about an hour of monitoring Ms W had a bath.

At 11.00am Ms W was placed back on the CTG machine when she got out of the bath. The trace was non-reassuring with foetal decelerations.  At this point she was prepared for theatre to undergo an emergency caesarean section.

At 12.07pm  the infant was born weighing 3.5kg.  The liquor was described as “meconium 3” and  ‘Baby W’ was described as being in “poor condition – no spontaneous resps, suctioned then positive pressure ventilation given for about 1 minute – spontaneously breathing and grunting”.  The Apgar scores were 3 at one minute, 5 at 5 minutes and 5 at 10 minutes. Apgar scoring takes into consideration activity, pulse, grimace, appearance and respiration.  A score of 0-3 indicates “severely depressed”, 4-6 indicates “moderately depressed” and a score of 7-10 indicates the baby is in “excellent condition”. 

‘Baby W’ was shown to Ms W but then needed to be urgently transferred to the special care nursery for further management and resuscitation.

On arrival in the special care nursery the infant had grunting respirations and her oxygen saturations were in the 70s. ‘Baby W’ was noted to have some facial asymmetry as well as some mild contractures of her legs and, to a lesser extent, arms.  There was a query whether she had a congenital syndrome of some type. There were also concerns that she had a cardiac anomaly as she was poorly perfused, had sustained a significant hypoxic/ischaemic event, and also that she was suffering from meconium aspiration and pulmonary hypertension.  The infant was given fluids, prostaglandin (possibly for the purposes of preventing patent ductus arteriosus).  She was also given antibiotics. Inotropic medications soon needed to be commenced to support her cardiovascular system.

At 12.45pm Dr Bert Shugg, paediatrician, was called to treat the infant. Dr Shugg is the Director of Neonatal Services, North West Private Hospital, Clinical Leader of Paediatrics THO-North West, Associate Professor of Rural Paediatrics UTAS Rural Clinical School, and member of the Tasmanian Lead Clinicians Group.  Dr Shugg has worked at the NWPH for the past 8 years and was previously a consultant to the Neonatal Unit at the Royal Hobart Hospital (“ RHH”) for 15 years.

In his report for the coronial investigation Dr Shugg stated that ‘Baby W’ respirations were depressed at birth and she required resuscitation for 30 seconds by positive pressure ventilation by face mask. He stated that on arrival in the special care nursery respiratory support was commenced with high flow nasal cannula oxygen at 8 L/min.  The initial arterial blood gas showed significant metabolism acidosis.

Dr Shugg stated: “The diagnosis was not clear but a cyanotic congenital heart lesion was not able to be excluded given the absence of a paediatric echocardiography facility.  The lifesaving treatment was at that stage however independent of a diagnosis”.

At 2.30pm the coordinator of NETS (Newborn Emergency Transport Service) at the RHH was contacted and a request was made for a NETS retrieval team to transfer ‘Baby W’ to the RHH for further care and interventions at the neonatal intensive care unit (NICU) there. It is the role of NETS to determine the requirements of such requests, the most appropriate mode of transport and destination and to assist in the transfer.

At 6.20pm The NETS team (comprising Dr Alison Pearce, senior registrar, and Jane Stebbings, senior nurse) arrived by helicopter.  At this time the infant’s care was handed over to them.  Dr Shugg states: “I was informed that in view of the baby’s condition that transport was to be then arranged via a fixed wing aircraft to the Royal Children’s Hospital in Melbourne, Neonatal Intensive Care, with paediatric cardiac input”.

Dr Shugg states: “Because of the acute and now deteriorating circumstance of the baby, the NETS team via the then consultant, Dr Tony De Paoli, requested that I remain to continue supporting the infant’s management.  Arrangements with the Royal Children’s Hospital were made by Dr De Paoli from his base in Hobart”.

At 7.14pm the infant was ready for onward transport to the Royal Children’s Hospital (“RCH”) in Melbourne – but a suitable transport platform for the journey to Victoria (aircraft with appropriate stretcher/cot transfer base) was not available.  Dr De Paoli stated:

“Although logistical plans were made between myself, Ambulance Tasmania, and Victorian teams, the plane was subsequently re-tasked for another patient without discussion.  ‘Baby W’ was sufficiently stable for transfer at this time, with an intent to transfer her to the RCH Melbourne, as the differential diagnosis included cyanotic congenital heart disease. An additional therapy which may have helped’Baby W’ at this time, but is not currently available on our NETS transport system, is that of inhaled nitric oxide.”

At 7.26pm Dr De Paoli was informed by Tasmanian Ambulance Communications that unfortunately the only available fixed wing aircraft was retrieving a patient from the Tasmanian West Coast for transport to Burnie, with a projected time of arrival at Wynyard airport of 8.20pm.  In addition, as this was the reserve aircraft, potential departure was to be further delayed about 1.5 hours due to the need to fly from Wynyard to Hobart and back again to Wynyard as the plane specific ‘cot transfer base’ was in Hobart. The cot base required had been transported back to Hobart with the helicopter.

At 8.09 pm there was a discussion between Dr De Paoli and NETS Victoria to discuss the feasibility of an aircraft being dispatched from Victoria.  The consensus was that no time advantage would be gained by sending a Victorian aircraft to Burnie to conduct the retrieval.  The Tasmanian helicopter is not able to transport to Melbourne.

At 9.39pm Dr Pearce (NETS retrieval doctor) telephoned Dr De Paoli to inform him that she had contacted Ambulance Tasmania requesting an update on the estimated time of departure, and that Ambulance Tasmania said that the aircraft had not left Wynyard to retrieve the cot transfer base from Hobart. At that stage Dr Pearce expressed concern regarding the infant’sworsening clinical state.

At 9.44pm Dr De Paoli called Tasmanian Ambulance Communications and was informed that a decision had been made by the Tasmanian Medical Retrieval Coordinator for the plane to remain at Wynyard airport to wait for an elderly man with ischaemic heart disease at NWRH Burnie who required transfer to Hobart.  Neither Tasmanian Ambulance Communications nor the Tasmanian Medical Retrieval Coordinator called the NETS team at Burnie (Dr Pearce, Jane Stebbings,) or Dr De Paoli to discuss this change in plan. The change in plan resulted in the failure of the plane to fly to Hobart at the expected time to pick up the cot base.   

At 9.40pm Dr Shugg and the NETS team were informed that a transfer by the fixed wing aircraft was at least another two hours away. Dr Shugg states, and I accept, that this was an unusual delay in his experience of neonatal transfer from the NWRH.

At 10.03pm ‘Baby W’s’ clinical condition had deteriorated further to a point of profound mixed metabolic and increasing respiratory acidosis. ‘Baby W’ was not sufficiently stable for transport, although in any case the aircraft was still not available.  Manipulation of drug therapies and a further chest x-ray to exclude pneumothorax were undertaken at 11.11pm. 

Following further discussions with Dr De Paoli, Dr Shugg advised the parents that the infanthad no prospects of survival and that it was their advice that treatment be withdrawn.  They accepted this advice and ventilation was ceased at about 11.30pm.

At 12.07am on 24 November 2011 ‘Baby W’ passed away.

Dr Donald Ritchey, Forensic Pathologist, performed ‘Baby W’s’post mortem examination. Dr Ritchey, in his report, stated:

“The cause of death of this 1 day old infant Caucasian girl, ’Baby W’, was aspiration pneumonia complicating large-volume aspiration of amniotic fluid and meconium…

…The autopsy revealed a well-developed infant Caucasian girl without apparent congenital abnormality.  The internal organs also appeared normal for a newborn infant.  Specifically the heart had four chambers, with a membrane-protected, patent foramen ovale, normally positioned great vessel, patent ductus arteriosis, and normal appearing coronary anatomy.

Microscopic sections of lung revealed florid aspiration of amniotic fluid as evidenced by intra-alveolar epithelial cells, lanugo hair and meconium debris.  In addition there was focal but florid aspiration pneumonia.

These findings are interpreted by me to suggest that ‘Baby W”suffered a large volume aspiration of amniotic fluid containing meconium (partially digested fluid that has passed through the foetal gastro-intestinal tract and passed into the fluid).  The large volume aspiration in turn caused inflammation within the lung (aspiration pneumonia) leading to respiratory distress and death.

The changes seen in the placenta (meconium staining causing green discolouration) support the view of meconium aspiration as the inciting event.  The placenta, membranes and umbilical cord were otherwise non-contributory.”

I accept the conclusion of Dr Ritchey that ‘Baby W’ died as a result of large-volume aspiration of amniotic fluid and meconium.

Baby W Treatment and Delay in Transfer:

Whilst the infant died of natural causes, there has arisen the complex question as to whether her death could have been prevented by more timely transfer to an appropriate treating hospital. This aspect of the investigation has unfortunately caused substantial delay in concluding the finding due to the necessity to await and consider the reports received. These reports have also assisted me to chronologically set out (above) the infnat’s  treatment and matters associated with her transfer.

Ultimately I have come to the conclusion, based upon the advice of Dr Shugg, Mr Morgan, Dr De Paoli, and Dr Tony Bell (coronial medical consultant), that a general lack of resourcing, the regular aircraft being out of service, and a considerable spike in demand prevented ‘Baby W’s’ transfer to either the RHH and/or the RCH at an earlier time. I am satisfied that the situation that occurred was most unusual. However there were also systems issues that could have improved the timeliness of the transfer.  I will deal with them below. They have been addressed in detail with good outcome.

Firstly, I note that at the time of the initial NETS request to transfer’Baby W’ to the RHH the fixed wing air ambulance was already tasked on an adult medical retrieval transferring a severe cystic fibrotic patient to Melbourne.

Shortly after receiving the request from NETS at 3.17pm several further requests were received by the communications centre for urgent response:

1. 3.54pm - A patient with biliary dust obstruction requiring transfer from NWRH to LGH.
2. 4.21pm - Request to re prioritise patient with Non-ST Segment Elevation Myocardial Infarction (NSTEMI) and pulmonary oedema from NWRH to RHH whose condition had deteriorated. (This patient had already been delayed greater than 24 hours due to high case load).
3. 4.32pm - Premature Labour from Queenstown to go to the NWRH. (This patient was transported by road).
4. 4.55pm - Request for urgent evacuation of a 7 year old female post road traffic accident from Strahan.

The fixed wing air ambulance was scheduled to depart Melbourne for Tasmania at 4.30pm which would have resulted in an arrival time at Hobart of 6.30pm to collect the NETS team. Given such information the Ambulance Tasmania (“AT”) duty manager contacted Police Search and Rescue to determine the availability of the Police Rescue Helicopter for the NETS transfer. The decision was therefore made to use the helicopter. At that stage it was not envisaged that the infant would require transfer to the RCH in Melbourne, a journey not suitable for helicopter. The difficulties with the unavailability of the correct transport cot as well as the competing demands of other urgent transfers were also contributors to the unusual delay in achieving the infant’s transfer.

I have received an informative and helpful report from Mr Dominic Morgan, Chief Executive Officer of Ambulance Tasmania.

In relation to the delay regarding the cot, Mr Morgan states that the regular air ambulance was ‘off line’ on 23 November 2011 as it required a major line check.  Therefore the RFDS fixed wing that was in service on this day was an alternate aircraft and it had a different stretcher configuration to the primary aircraft and which required an interface plate to secure the NETS cot to the air craft stretcher. He states:

“As the NETS team was transported to the NWRH via helicopter where the cot remained on the standard ambulance stretcher neither the NETS team nor the police helicopter crew were aware that they would need to take the interface with them so that they would be able to return via fixed wing air ambulance and subsequently this was left in Hobart as initially it was anticipated they would return to Hobart in the helicopter, that is, the same way the cot was transported to the hospital.

Once the fixed wing flight paramedic was tasked with the case to transfer the team to Melbourne he identified the need for the interface to enable the cot to be loaded onto the fixed wing aircraft (aviation regulations will not allow the cot to be transported unless secured by an approved restraint system).

On identification of the issue the original plan was for the aircraft to return to Launceston, change flight crew, then go on to Hobart to collect the interface then proceed to Wynyard to collect the NETS team as the patient was still being actively treated and assessed with an unknown scheduled “ready time”.

On returning to Launceston to change flight crew the aircraft was tasked to proceed to Strahan for the injured child before proceeding to Hobart on clinical grounds previously described.

The air ambulance arrived at Wynyard from Strahan at 20:25 hours (8.25pm).

Following consultation with the Adult Retrieval Service Clinical Co-Ordinator it was decided to transfer the cardiac patient to Hobart with the aircraft going to Hobart to collect the NETS cot interface rather than have the plane return unloaded and further delay treatment to that patient.”

On behalf of NETS Dr De Paoli summarised the issues as follows:

1. “The response time for the retrieval of ‘Baby W’ was slow when compared with median Victorian times.

2. Tasmanian NETS and Ambulance Tasmania do not have a formal system in place to classify the urgency of cases at the time of referral to facilitate timeliness of response, case prioritisation, and formal audit/benchmarking – this is being progressed.

3. The Tasmanian air retrieval system was unable to provide a fully equipped aircraft in a timely fashion to conduct ‘Baby W’s’ transport from Burnie to Melbourne.  The infant ultimately died before an aircraft was ready.  In context of competing demands this is largely a symptom of resource limitation, ie, the availability of only one fixed wing aircraft for Tasmanian emergency medical retrievals.  The absence of stretcher/cot transfer base for the reserve aircraft was a significant factor.  Since this case our RHH NETS team has undertaken considerable work in collaboration with Ambulance Tasmania to streamline and document logistical processes, including stretcher/cot base considerations, in order to reduce transport delays.

4. The decision, without consultation with the NETS team, to keep the aircraft in Wynyard to await an adult patient for transfer to Hobart barred the possibility of a discussion regarding the infant’s critical state and appropriate patient prioritisation, and consequently caused further delay.

5. Nitric oxide was not available as a potential therapy during retrieval.  Tasmanian NETS is planning to acquire/purchase a portable inhaled nitric oxide system for the NETS transport cot to assist in the management of critically ill babies.”

Mr Morgan states a Root Cause Analysis of the situation was undertaken by Ambulance Tasmania.  The recommendations were:

1. “AT and NETS establish a common communication protocol similar to AT “sit rep” used by paramedics.
2. The Adult Retrieval Co-Ordinator is advised as soon as a competing case arises with a NETS case.  The Adult Retrieval Co-Ordinator should then contact the NETS co-ordinator, via the CDO, and establish the priority of the cases in question.
3. When arranging for retrievals by multiple transport modes i.e. team up by one mode, back by another, the State Communications staff must contact each party involved at the initial tasking, to ensure equipment and procedural planning is understood by all parties.
4. The draft AT inter-facility transfer procedure is currently being consulted upon which further clarifies communication pathways be supported.
5. Changes to vehicle tasking during the conduct of retrieval be notified by Comms to the co-ordinator of that case – NETS or Adult Retrieval.
6. The need for clear communication be highlighted to all parties involved – NETS, State Communications, Air-Crew, Clinical Co-Ordinator.
7. A checklist of differing aircraft specifications should be kept in the State Communications Centre for easy reference.”

Mr Morgan states that all of the recommendations of the review have been implemented. He further states:

“In July 2012 AT entered into a new aero-medical contract with the RFDS South Eastern Section for the provision of aircraft pilots and base infra-structure, this agreement saw the introduction of a new aircraft with the latest available medical fit-out.  This agreement also provides that an alternate aircraft used to provide the service should have the same medical configuration.

As Tasmania has only a single fixed wing air ambulance the need to prioritise competing case [sic] is a critical component of the service.  The prioritisation is undertaken through a clinical assessment made by the Retrieval Service Clinical Co-Ordinator [sic] a general principle is that a critical patient that is outside a tertiary health facility is prioritised above one that is under the care of senior clinicians within a tertiary facility.

AT has access to the Tasmania Police rescue helicopter when required for medical responses however the current helicopter has limitations:

• It does not have long range capabilities and only has limited aero medical fit-out;
• It is restricted by speed and range;
• It is a non-pressurised aircraft; and
• It has limited cabin space making any clinical intervention required en route difficult.

AT acknowledged that a number of communication issues on this occasion created by the complexities of the competing priorities caused extended delays for the transport of Baby W.  In a small State with limited aero-medical resources competing priorities will always arise with these being triaged by senior clinicians to ensure the most effective utilisation of the resource and the balance of providing the greatest good to the greatest number is at the forefront of the operational and clinical decision making.”

The coronial medical consultant, Dr Tony Bell, has reviewed the circumstances of the proposed transfer of the infant and her care generally. He states that “the two systems, Ambulance Tasmania and Tasmanian NETS systems, have steadily worked together to improve the services provided. Good progress appears to have been made”. I accept that this is the case. I also accept all involved were doing the best they could to provide ‘Baby W’ with care. Dr Bell states that the decision not to transfer to the RHH but to the RCH was sound in the circumstances of the infant’s presentation.

Finally, the question arises as to whether the infant’s death would have been preventable had earlier transfer occurred.

Dr Shugg states that ‘Baby W’s’ chances of survival with neurological sequelae may have been better in a tertiary hospital with a neonatal intensive care unit.  He states:

“These facilities are not immediately available for all Australian citizens particularly those that choose to live in a regional environment.  As a provider of rural paediatrics and neonatal services I consider that the functioning of the Tasmanian Neonatal network is of high quality benchmarked against National and appropriate international standards.”

Dr Bell also states that transport to an intensive care unit for cases of meconium aspiration syndrome (“MAS”) is important resulting in generally good outcomes. Transfer is time critical but the outcomes are good.  Dr Bell states in his report;

“A small case control study suggests that 20% of infants with the condition have some neurodevelopmental impairment.

’Baby W’ may well have suffered persistent pulmonary hypertension of the newborn (PPHN) with persistent cyanosis. The association of PPHN with MAS occurred in 41% of cases of PPHN. The patient was treated for this complication. PPHN leads to persistent cyanosis and thus consideration of congenital cyanotic heart disease, which can only be diagnosed by echocardiogram. This led to the need for transport to Melbourne instead of Hobart (Appendix 1 describes the circulation differences between a foetal and adult circulation).

The development of assumed PPHN appears to have occurred before the arrival of the retrieval team at 18:20 hours. A major deterioration occurred at 19:30 hours after which the course was downhill.

At best guess arrival before 17:00 to 18:00 hours at the tertiary hospital was required to prevent death and severe hypoxic cerebral damage.

I believe that every effort was made in this case to save the Baby W.”

It is therefore very difficult to accurately assess the point in time when the infant may have survived in a tertiary hospital.  It is likely that she may have survived if, for example, she had been conveyed directly to the RHH by return in the helicopter. However, there would likely have been cerebral damage. This transportation, however, did not occur because of the  sound medical decision to change the destination to the RCH Melbourne due to the possibility of her suffering cyanotic congenital heart disease. At that time the appropriate aircraft was unfortunately not available for the reasons discussed.

I am satisfied that a thorough investigation has occurred into the circumstances surrounding ‘Baby W’ death. I am satisfied that an unusual set of events, including communications and systems deficiencies, prevented her timely transfer to either  RHH or RCH. I am further satisfied that all doctors, medical staff and personnel attempted to use their best efforts for ‘Baby W’ in the circumstances.

Finally I am satisfied that the issues surrounding ‘Baby W’s’ transfer have been appropriately addressed, and that those improvements have enhanced the efficiency of NETS and AT systems. I recommend regular reviews of the systems and processes into the future.

In the circumstances there is no need to make any further comment or recommendations.

I conclude this matter by conveying my sincere condolences to the family of 'Baby W'.

DATED:  17 September 2014at Hobart in the State of Tasmania.

Olivia McTaggart