Vasilis KTORAKIS · Prevention of Future Deaths report

On 28 May 2015, I commenced an investigation into the death of Vasilis Ktorakis, who died shortly after birth. The investigation concluded at the end of the inquest on 5 October 2015. (I apologise for the delay in sending this report.) I made an open determination and recorded a medical cause of death of:

1a acute perinatal asphyxia
1b underlying cause unknown.

Following a long labour at the Whittington Hospital, ████████ gave birth on Saturday, 23 May 2015. To the great surprise of the healthcare team, Baby Vasilis was born in an extremely poor condition and died very shortly thereafter.

Errors in Care

1. ████████ was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation (including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when ████████ was seen by a registrar at 2.40pm that afternoon, the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.

Having spoken to the registrar since, the consultant is unable to explain why that full review and medication commencement did not take place. It is therefore unclear whether this particular registrar, and indeed others on the unit, might be likely to make the same mistake again another time.

2. The notes recorded by that registrar fell significantly short of what can be expected in terms of recording a management plan.

Learning Lessons

3. At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing. This was an error of judgement that the registrar had not appreciated even by the time of the inquest, over four months after death, indicating that she had not received appropriate feedback. It is therefore unclear whether this particular registrar, and others on the unit, might be likely to make this same mistake again.

4. The first registrar was not asked to contribute to the hospital’s untoward incident investigation, so there was a systemic failure to understand the value of her input, resulting in a loss of learning for the organisation and for the registrar.

5. Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost. This seems to demonstrate a lack of a robust system for learning lessons.