Coronial
NSWhome

Inquest into the death of Jaxon McGrorey-Smith

Deceased

Jaxon McGrorey-Smith

Demographics

0y, male

Coroner

Decision ofDeputy State Coroner Lee

Date of death

2011-11-18

Finding date

2018-11-14

Cause of death

neonatal encephalopathy due to perinatal compromise

AI-generated summary

Jaxon McGrorey-Smith, a full-term neonate, was delivered by caesarean section after prolonged labour. He developed seizures and signs of hypoxic-ischaemic encephalopathy (HIE) within hours of birth, with MRI imaging confirming severe bilateral brain injury. After detailed discussions with the parents regarding prognosis, intensive care was withdrawn on day 2 of life, transitioning to palliative care. Jaxon died at home 27 days later. The inquest found that parents received adequate time for decision-making, had opportunities to review decisions, and that cessation of mechanical ventilation, anticonvulsants, nutrition and fluids constituted appropriate palliative care aligned with NSW Health guidelines. The commencement of morphine for comfort management was appropriately responsive to symptoms. The main learning opportunity identified was the potential value of specialised palliative care input and formalised advance care planning documents for neonates managed outside intensive care settings.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

neonatologyneurologyobstetricspalliative care

Drugs involved

oxytocindinoprostonephenytoinacyclovirmidazolammorphine

Clinical conditions

hypoxic ischaemic encephalopathyneonatal seizurescerebral infarctsmetabolic acidosismeconium aspirationrespiratory distress

Procedures

caesar section deliveryintubationventilationlumbar puncturecerebral MRI

Contributing factors

  • severe hypoxic-ischaemic encephalopathy
  • perinatal asphyxia during labour
  • prolonged bradycardia during induction of labour
  • assisted delivery failure requiring emergency caesarean section
  • bilateral cerebral infarcts

Coroner's recommendations

  1. A copy of the reports of Professor Dominic Wilkinson dated 7 September 2018 and 27 October 2018 be forwarded to the NSW Minister for Health, together with a transcript of the oral evidence of Dr C., Associate Professor Nick Evans, and Professor Wilkinson, given on 30 October 2018, for the Minister's consideration regarding further recommendation.
  2. NSW Minister for Health to consider whether the NSW Health End-of-Life Care and Decision-Making Guidelines (GL2005_057) ought to refer to palliative care professionals and the role that such professionals might play in end-of-life care and decision-making for infants and children.
  3. NSW Minister for Health to consider whether the NSW Guidelines ought to refer to resuscitation plans and advance care plans in general, and for neonates less than 29 days old in particular.
Full text
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