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Investigation and inquest
On the 16th February 2018 I commenced an investigation into the death of Elisa Fuller. The investigation concluded at the end of the inquest on the 10th October 2019. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A Cardiac Arrest, 1B Unexplained idiosyncratic reaction to suxamethonium, 2 Prematurity.
Circumstances of the death
At 10.46 hours on the 9th February 2018 Elisa Fuller was delivered by elective Caesarean section at 36 weeks gestation due to placenta praevia. Elisa showed no evidence of compromise at delivery. From approximately 12.50 hours she began to display emerging symptoms of respiratory distress. Concerns about these symptoms were not escalated to either a Senior Midwife and / or a Senior Paediatrician. No medical review occurred until approximately 16.25 hours. This resulted in Elisa’s admission to the neonatal unit being delayed. However that delay did not contribute to her deteriorating condition. As her condition continued to deteriorate she was intubated. Premedication with morphine and suxamethonium (a muscle relaxant) was prescribed prior to intubation together with atropine. These drugs were administered at approximately 19.27 hours, and immediately thereafter Elisa suffered an idiosyncratic reaction to suxamethonium which triggered a cardiac arrest. Full resuscitation efforts were carried out, to which Elisa did not respond. The underlying cause of her reaction to the relaxant remains unclear. It is likely to be related to a neuromuscular disorder, but no genetic cause has been identified. Resuscitation efforts were ceased at 20.28 hours, and Elisa was pronounced deceased.
Coroner’s concerns
Although I acknowledge that the Trust have put in place systems to address the second concern. In relation to the first concern, further training has been put in place. However there remains work to be done.
(1) Whether there is appropriate support and systems in place to encourage Junior Midwives and Junior Doctors to escalate any concerns they have to more Senior Colleagues,
(2) Whether there is sufficient understanding of the need to retain placentas post delivery for a specified time period prior to disposal.
Information checked against the published report and official responses