Deceased
Elsie Coghill
Demographics
0y, female
Coroner
Decision ofDeputy State Coroner Dillon
Date of death
2013-05-27
Finding date
2016-03-11
Cause of death
Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnormality from antenatal distress, sudden unexpected apnoeic episode during transfer to intensive care, and undiagnosed bilateral tension pneumothoraces
AI-generated summary
Elsie Coghill, a newborn, died from hypoxic ischaemic encephalopathy due to multiple factors including an underlying lung abnormality from antenatal distress, an undetected apnoeic episode during transfer, and undiagnosed bilateral tension pneumothoraces. The mother attempted VBAC (vaginal birth after caesarean) after an earlier planned elective caesarean was not completed when the patient presented at 40+ weeks. Vacuum delivery was prolonged but deemed appropriate. Critical gaps included: failure to follow planned antenatal care (elective caesarean not booked at 40 weeks), failure to call a paediatrician to delivery despite guidelines, inadequate observation during transfer to SCN, and lack of systematic protocols for instrumental deliveries. The pneumothoraces were undiagnosed until resuscitation was underway in SCN. While multiple factors were suboptimal, causation remains uncertain—the underlying lung abnormality and undetected apnoea during transfer appear central. Clinicians should ensure delivery plans are followed, follow institutional neonatal resuscitation guidelines regarding paediatrician presence, maintain close colour/respiratory observation during transfer, and implement checklists for instrumental deliveries.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
32y · Female·Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystit…
A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty p…
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…
0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …
Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.