Medical Negligence Patient Safety Item 1.11

MEDICAL NEGLIGENCE PATIENT SAFETY ITEM 1.11

PATIENT SAFETY ACT 2023

John Whelan Solicitor with specialist expertise in Medical Negligence and Patient Safety gives an example of a Notifiable Incident as envisaged by Item 1.11 of the Act. 

There are 13 notifiable incidents set out in the Act but other notifiable incidents may be introduced by Ministerial regulation under Section 8 of the Act.

Item 1.11

An unanticipated or unintended perinatal death where a child was born with or having achieved a prescribed gestational age and the prescribed birth weight who was alive at the onset of care in labour from any cause related to or aggravated by the Management of pregnancy and the death did not arise from or was a consequence of or wholly attributable to the illness of the child or an underlying condition of the child.

An example of an unanticipated or unintended perinatal death.   A woman was admitted for a routine labour at full term, with a healthy pregnancy and no signs of complications.    The child was born at a normal gestational age and had a normal birth weight, and showed signs of life immediately after birth. 

However, during the management of the delivery, there was a delay in the provision of appropriate resuscitation.    The baby has some mild respiratory distress immediately after birth a condition which is not uncommon in labour but is often managed effectively with simple interventions such as suctioning the airways and assisting with breathing.   Unfortunately, due to staff inexperience, these interventions were delayed, and the baby was left without proper respiratory support for an extended period.   As a result, the baby suffered a brain injury caused by lack of oxygen, which led to multi organ failure and death a few hours later.

The cause of death was directly related to the management of the pregnancy and labour.  Despite being a healthy child born at the correct gestational age and weight, the failure to intervene quickly enough when respiratory distress was detected led to unintended and unanticipated perinatal death.     The death did not arise from any underlying condition of the baby or the mother, instead, it was due to a clinical mistake in managing the baby’s immediate post birth care.

This case shows how mismanagement during labour or immediate post birth care can lead to a tragic and preventable perinatal death, even when the baby is otherwise healthy and has reached a prescribed gestational age and birth weight.   The outcome was not attributable to any illness or condition of the child but rather to the way the pregnancy and birth were managed.  

For more detailed insights into how the Patient Safety Act 2023 impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice https://www.whelanlaw.ie/news/medical-negligence-and-patient-safety/