Inquest into the death of Jasmine Chiang

Contributing factors

• Primary idiopathic persistent pulmonary hypertension of the newborn (PPHN)
• Secondary pulmonary haemorrhage
• Failure of pulmonary vascular relaxation at birth
• Right-to-left shunting through fetal circulation pathways

Coroner's recommendations

1. Consideration be given to the introduction of a policy applicable to NSW Health Pathology requiring that the postmortem examination of all reportable neonatal deaths be performed jointly by a forensic pathologist and a perinatal and paediatric anatomical pathologist in a forensic facility.
2. In the event that the first recommendation is unable to be implemented due to reasonable workforce and other limitations, consideration be given to the introduction of a policy applicable to NSW Health Pathology requiring that the postmortem examination of all reportable, non-suspicious, non-traumatic neonatal deaths occurring in NSW hospitals be performed by a perinatal and paediatric pathologist. The postmortem examination should be performed at The Children's Hospital at Westmead, Sydney Children's Hospital at Randwick, or John Hunter Children's Hospital, depending on geographic location.
3. In the event that the first recommendation is unable to be implemented due to reasonable workforce limitations, consideration be given to the development and implementation of structured guidelines, applicable to NSW Health Pathology, to facilitate consultation between forensic pathologists from the Department of Forensic Medicine and perinatal and paediatric pathologists from paediatric pathology units. Such guidelines should provide for any such consultation to be appropriately documented, and for any resulting autopsy report to be jointly authored by the case forensic pathologist and consulting perinatal and paediatric pathologist.