Coroner's Court of Western Australia

Inquest into the Death of Ashlee Jade REINDL

Inquest into the Death of Ashlee Jade REINDL

Delivered on :  7 July 2023

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Ashlee Reindl was born in Joondalup Hospital on 27 October 2019 and she died the same day. Her death was unexpected and was reported to the State Coroner. Following an inquest, the Deputy State Coroner found that Ashlee died due to placental abruption and sepsis secondary to chorioamnionitis, with meconium aspiration, on a background of delayed maturation of the placenta, in the settings of induced labour for a prolonged pregnancy.

Ashlee’s parents had already delivered four healthy children vaginally and this pregnancy was uneventful, so the plan had been for Ashlee to be delivered vaginally as well. Labour had been induced after her mother went post-dates, and initially everything seemed to be going as well. However, the labour did not progress. It eventually became apparent that the baby was in distress at around 7.30am, but a decision was not made to perform a caesarean section until around 10.20am, with Ashlee being delivered by emergency caesarean section at 10.55 am. During this procedure, it became apparent a massive placental abruption had occurred, and there was also evidence of infection in the placenta. Ashlee was born in a lifeless state and, although spontaneous circulation was eventually achieved, she never breathed on her own and a decision was eventually made that they should withdraw active treatment.

An internal review of the medical care, and review by an independent expert, reached the conclusion there was evidence on the CTG at least by 7.45 am, if not earlier, that should have prompted a senior medical review and decision to proceed to caesarean section delivery. However, the staff involved did not appreciate the seriousness of the situation at that stage. The expert evidence concurred that earlier delivery may have prevented Ashlee’s death.

An inquest was held on 7 to 9 February 20223 to determine whether there were opportunities missed to provide earlier medical treatment during the labour and delivery that might have saved Ashlee’s life, and if so, the reasons why that occurred. The inquest took into account the results and recommendations of a root cause analysis and independent expert review of the case.

The Deputy State Coroner found that death occurred by way of misadventure, given the involvement of the induction in the cause of death.

Catch Words : Discretionary Inquest : Placental Abruption : Chorioamnionitis : CTG : Induced Labour

Last updated: 18-Jul-2023

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