Andrei Ciprian Matei · Prevention of Future Deaths report

On the 6th January 2011 I opened an inquest touching the death of ,Andrei Ciprian Matei aged 65 minutes. The investigation concluded at the end of the inquest on the 4th December 2013. The conclusion of the inquest was “Narrative Conclusion”, the medical case of death was ;1a Peripartum asphyxia , 2 Abnormal placental maturation.

On the 12th December 2010 at 18.58 Andrei Ciprian Matei born in Hospital following an emergency caesarean section. Andrei was suffering with progressive intrapartum hypoxia that is likely to be related abnormal placental maturation.

The decision to commence oxytocin and to opt for forceps delivery rather than an emergency caesarean section delivery at 18.35 hrs were adverse factors that contributed to the development of the foetal hypoxia.

There were concerns raised that the baby Matei’s mother, who had trouble speaking and understanding English, did not have an interpreter with her when taken to theatre

There was a failure to follow the consultant plan and NICE Guidelines in not taking a further foetal blood sample which was likely to have been abnormal if taken at 18.09

There was a failure to pick up the abnormality in the CTG trace from 17.20 onwards which by 18.00 hrs was likely to have been pathological.

It is likely that a significant hypoxic insult occurred at the time of foetal head rotation and the application of forceps.

There was a lost opportunity between 18.09 hrs and 18 20 hrs for an emergency delivery which if taken is likely, depending on the method of delivery chosen, to have led to a greater chance of survival.

(1) There was no national guidance on the role of interpreters during labour in particular when the interpreter is required in theatre.