Kristian Andrew Jaworski · Prevention of Future Deaths report

On the 9th July 2015 I opened an investigation touching the death of Kristian Andrew Jaworski , 5 days old. The inquest concluded on the 21st March 2016 The conclusion of the inquest was “Complications of delivery”, the medical cause of death was 1a Asphixia as a consequence of prolonged and extended instrumental delivery.

On the 20th September 2012 ████████ at 16.18 was delivered of a son by forceps.

████████ was told that she had a narrow birth canal at the time that her first child was born and was told to ask for a caesarian section were she to have a further child if it is likely that this was said.

It is likely that the obstetrician who delivered the first child did tell ████████ firstly that the birth canal was narrow and secondly that ████████ was told to ask for a caesarian section on the next occasion.

████████ medical notes made no reference to these matters.

On the 18th May 2015 ████████ when planning for the delivery of her next child raised with a Consultant Obstetrician that during her first birth she had been described as having a narrow birth canal and that the birth had been traumatic for her ,she had some decelerations and then episiotomy and a 2nd degree tear and was concerned about a similar problem and ████████ added that she was told to ask for a caesarean section .

A plan was made for vaginal delivery with the option of an emergency caesarian section and there matters rested.

On the 27th June 2015 ████████ attended North Middlesex Hospital Triage following the spontaneous rupture of her membranes at 16.30. ████████ was examined and discharged home.

At 23.45 ████████ returned and was again discharged home. At 1.40 hrs on the 28th June 2015 ████████ returned to the Triage at North Middlesex Hospital and was transferred to the labour ward at 2.10 hrs.

At 4.30 the Registrar was summoned to review fetal heart rate and decelerations.
At 4.43 a fetal blood sample was taken and the resultible abnormal.

At 5.00 the progress was discussed with the Registrar and the Consultant Obstetrician agreed with the plan to take ████████ to theatre. The Consultant Obstetrician believed that the purpose of taking ████████ to theatre was to deliver the child by caesarean section.

During this period there continued to be an abnormal CTG trace but given the normal fetal blood samples this was reassuring.

In theatre the Registrar made an assessment of ████████ birth canal and reached the conclusion trial of instruments would be appropriate.

At 5.55 delivery was attempted by Ventouse and there was descent with each of 3 pulls.
At 6.12 a decision was taken by Registrar to switch to forceps and a fourth pull resulted in no descent. A more junior doctor present was asked to give a 5th pull again with no descent. A fetal bradycardia with a heart rate below 100 was noted and the decision taken to abandon instrumental delivery.

A category 1 caesarean section was then necessary and was started using an epidural and then a general anaesthetic.

Kristian was born at 6.39 with poor Apgar scores and was soon transferred to University College Hospital where he died on the 3rd July 2015.

The cause of death is likely to have been Asphyxia as a consequence of prolonged and extended instrumental delivery.

To the Department of Health

That there was a presumption in favour of vaginal delivery based partly of cost that needed to be rebutted.