Re: Elisa Fuller 

Three-day inquest into the death of a baby who was born prematurely and died from cardiac arrest shortly after birth. The principal issue was the cause of the cardiac arrest, which the Coroner concluded was a combination of her deterioration in respiratory condition and a reaction to muscle relaxant therapy administered prior to intubation.

Other issues included: (i) the administration of steroids prior to delivery; (ii) the timing of Caesarean delivery; (iii) the midwifery, paediatric and neonatal care provided; (iv) the staffing and cot capacity; and (v) causation. It comprised evidence from a number of clinicians. The Coroner was persuaded to instruct an expert Neonatologist to give evidence at the inquest itself. The significance of this case was that despite the totality of the evidence over three days, no clinician was able to identify the likely cause of death. It was an extremely unusual set of circumstances which resulted in some of the most experienced clinicians in this field of work giving an educated guess at most. However, the Coroner saw fit to raise a Prevention of Future Deaths report with the Trust.