Elton Deutekom · Prevention of Future Deaths report

On the 18th, 19th and 20th November 2024, evidence was heard touching the death of Master Elton Michael Deutekom. He had died on the 12th January 2022, thirty seven minutes after he had been born on labour ward at Chelsea and Westminster Hospital.

Medical Cause of Death

I a. Acute perinatal hypoxia/ischaemia (“perinatal asphyxia”)
b. Placental abruption

II Placental delayed chorionic villous maturation

Elton’s mother was transferred to labour ward at Chelsea and Westminster Hospital from the community at 01:25 on 12th January 2022. Her labour initially progressed well.

At approximately 0320- 0330 she suffered an abrupted placenta. As a result, Elton suffered an acute hypoxic ischaemic injury. This was undiagnosed by those caring for Elton’s mother despite a sharp change in her clinical presentation manifesting as severe pain, strong contractions and rapid progression to push and CTG (Cardiotocograph) changes consistent with hypoxia from 0334, when his mother was reattached to the monitor.

Elton’s baseline heart rate had gone up significantly, increasing by 30 beats per minute, followed by decelerations. There was no heart rate detected after 0414.

This change in base rate followed by decelerations was unrecognised by the obstetric registrar, despite her being in the room with Elton’s mother from about 0335 to at least 0348. The registrar relied on the historic CTG trace, rather than the trace at the time of her assessment. This was a serious failure that contributed to Elton’s death.

The midwife caring for Elton and his mother did not seek assistance from the obstetric team nor the senior midwifery team, despite recognising that the CTG trace was abnormal from 0355 hours at the latest. This was against training and guidance. This was a gross failure that contributed to Elton’s death.

The labour ward co-ordinator responded to hearing Elton’s mother screaming at approximately 0420 and allocated a senior midwife to assist. Neither recognised how long Elton had had an abnormal CTG. The emergency bell was not activated until 0430.

The emergency team responded promptly, and Elton was delivered by forceps at 04:35.

Despite resuscitation his life could not be saved, and he was recognised as life extinct at 05:12.

If Elton had been recognised as suffering with hypoxia and delivered before 04:05 on the balance of probabilities, he would have survived.

Conclusion of the Coroner as to the death:

Natural Causes contributed to by neglect.

1. That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths to coroner- either late or not at all, and this raises the possibility that lessons may not be learned from the investigation of these deaths that may save the lives of others.

2. That Chelsea and Westminster hospital may not be complying with the duty of candor to disclose evidence relevant to a death to the coroner until forced to by court directions made in public, which thus raises the same concern as above.

3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.

4. That the labour ward is understaffed.

5. That newly qualified midwives should have more supervision whilst they are managing women in labour.

6. That there is no regular review system for CTGs on the central CTG monitoring board.

7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths.

8. That the neonatologists at Chelsea and Westminster are not passing sufficient and appropriate information to the pathologists when consented post- mortem examinations occur such that the cause of death found by the pathologist may be inaccurate.

9. That neonatologists in other hospitals may not be appropriately reporting deaths to the coroner.