Remi Nana KODUAH · Prevention of Future Deaths report

On 30 November 2018 I commenced an investigation into the death of Remi Nana KODUAH aged 1 Days. The investigation concluded at the end of the inquest on 14 March 2022. The conclusion of the inquest was that:

Baby Remi Nana Koduah was born on 22 November 2018 at 23.57. He died on 23 November 2018 at 00.46 at Leighton Hospital. He died as a result of exsanguination due to ruptured vasa praevia. The care and treatment of Remi's mother prior to delivery was appropriate and reasonable, vasa praevia being a rare condition that could not reasonably have been diagnosed before Remi was born. Upon discovery at birth there were a number of missed opportunities during resuscitation but it cannot be said that these caused or contributed to Remi's death.

On 22 November 2018 ████████ Remi’s Mother attended the maternity unit at Leighton Hospital for induction of labour. Her pregnancy had been relatively normal and Remi was full term with all scans confirming a healthy baby. Her waters broke at around 7.30pm and blood was noticed shortly afterwards. She was moved to the labour ward and then upon a visit to the toilet suffered a significant show of blood and returned back to the ward. Fetal heartrate monitoring was difficult but when a reading was obtained around 11pm it was of concern and a category 2 C-Section was authorised. This was carried out at 11.57pm Baby Remi was delivered. He was pale and floppy and very ill and taken into a resuscitation room. The placenta showed signs of rupture and a message was relayed to the neonatal team that vasa praevia had occurred. During resuscitation no bloods or drugs were administered. Neonatal bloods were not present in the resuscitation room and were located some 10 minutes away. Resuscitation was stopped at 00.46am. Dr ████████ Consultant Obstetrician at Bath Hospital was asked by the Trust for an outside opinion. He said in evidence that he had never come across a resuscitation room be separate from the operating theatre as communication between the 2 teams was key and that bloods should have been available.

(1) That the resuscitation area was separate to the operating theatre thus hampering effective communications between the obstetric team and the neonatal team.
(2) Neonatal bloods and adult bloods are not kept in the resuscitation room. Since Baby Remi’s death bloods have been moved to the labour ward which is 2 mins away but in time critical moments this may still be too far away.