KKH considering procedure to continuously document newborn's vital signs after 11-day-old baby dies: Coroner

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SINGAPORE: KK Women's and Children's Hospital (KKH) is reviewing its procedures to consider continuous documentation of a newborn’s vital signs, after a baby died of a type of injury that stems from a decrease in oxygen or blood flow to the brain.

State Coroner Adam Nakhoda encouraged the hospital to implement this practice, after finding that the lack of continuous documentation of the baby's vital signs "was not ideal". He made this note in a set of findings into the death of the baby made available over the weekend.

The 11-day-old baby died on Apr 12, 2021 of natural disease causes, and the case was referred to the coroner after the hospital alerted the police about the baby’s death. 

He was born via emergency Caesarean, with his mother on general anaesthesia, after vaginal delivery by vacuum and forceps was unsuccessful and a slow foetal heart rate was detected for eight minutes.

His mother had been admitted to KKH at 39+1 weeks of pregnancy, and had gestational diabetes mellitus during her pregnancy as well as a prior history of Graves’ disease - an immune system disorder that affects the thyroid gland.

However, her thyroid function tests were normal during pregnancy, as well as her antenatal ultrasound scan.

The boy was born with three tight loops of umbilical cord around his neck. The cord was cleared and he was noted to have a "fair cry" when delivered.


KKH's neonatal resuscitation team immediately attended to the baby after birth and placed him on a resuscitator.

His initial heart rate was low, and he had borderline oxygen saturation, so he was given continuous positive airway pressure (CPAP) via nasal prongs until his condition improved.

The CPAP was discontinued at six minutes post-delivery, with the baby observed to be vigorous and have a "good cry". The rest of the examination findings were normal.

At about 5am, the doctors at the operating theatre were called away to attend to a Code Blue activation, referring to a medical emergency.

The baby remained in the operating theatre in the care of a senior staff nurse named only as SSN KJ in court documents. He was to be transferred to the special care nursery ward for observation.

SSN KJ weighed and measured the baby before placing him back on the resuscitator. According to her, measurements of the baby's oxygen saturation and heart rate via a probe attached to his pa...

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