Coronial
NSWhospital

Inquest into the death of Serena Lee

Deceased

Serena Lee

Demographics

1y, female

Coroner

Decision ofDeputy State Coroner Hosking

Date of death

2021-11-01

Finding date

2026-03-17

Cause of death

Obstructive sleep apnoea occurring in the context of significant, unrecognised hypoglycaemia associated with intrauterine growth restriction

AI-generated summary

Serena Lee, born 31 October 2021, died at 2 months from obstructive sleep apnoea in the context of severe, unrecognised hypoglycaemia associated with intrauterine growth restriction (IUGR). She was discharged from Campbelltown Hospital after 7 hours into a Midwifery Support Program despite being small for gestational age (5th centile), exhibiting IUGR with head-sparing growth pattern, and meeting clear policy criteria requiring glucose monitoring and inpatient observation. The discharging paediatrician, Dr Hewa-Gamage, failed to identify these risk factors, misunderstanding hospital policy as applying only a 2300g weight threshold. No blood glucose monitoring was performed despite Neonatal Hypoglycaemia Management Guidelines explicitly listing SGA and IUGR as indications for glucose monitoring. The midwives performing the home review recognized poor feeding but lacked glucometers and were influenced by outdated guidance regarding feeding frequency. The coroner found the death preventable and recommended investigations into the discharging doctor's practice.

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

Specialties

neonatologymidwiferyobstetricspaediatrics

Error types

diagnosticsystemdelay

Clinical conditions

intrauterine growth restrictionsmall for gestational agehead-sparing growth patternhypoglycaemiaobstructive sleep apnoeapoor feeding

Contributing factors

  • Premature discharge from hospital after 7 hours to Midwifery Support Program
  • Failure to identify small for gestational age status
  • Failure to identify intrauterine growth restriction and head-sparing growth pattern
  • Failure to recognize hypoglycaemia risk and perform blood glucose monitoring despite clear policy indications
  • Misunderstanding of hospital discharge policy by discharging paediatrician
  • Absence of glucometers available to Midwifery Support Program midwives
  • Reliance on outdated guidance regarding feeding frequency in newborns
  • Poor feeding not adequately actioned by midwives during home review
  • No consultant paediatrician review prior to discharge
  • Cognitive bias by midwives assuming appropriateness of discharge based on hospital clearance

Coroner's recommendations

  1. SWSLHD conduct an audit to ensure equipment identified in MSP Policy (glucometers and other equipment) is available, working, properly calibrated, and staff are trained in its use
  2. SWSLHD immediately ensure that material relied on by MSP midwives and handed to new parents is up-to-date and consistent with current best practice
  3. SWSLHD consider further amendment to MSP policy to provide guidance on circumstances requiring neonatal blood glucose monitoring, including consideration of requiring or recommending monitoring where there have been two successive feeds missed
  4. SWSLHD consider undertaking review of MSP Policy including seeking input from midwives currently working in MSP with view to amending policy to exclude patients not considered low risk from the perspective of the midwives
  5. Medical Council of NSW review and/or investigate Dr Danesh Hewa-Gamage's care of Serena and his decision to discharge her
Full text
Official source Archived copy

Related cases from NSW

NSWhospital2024-04-12

Inquest into the death of Everett Carleton

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 …

obstetricsneonatologycommunicationprocedural
NSWhospital2023-08-22

Inquest into the death of AN

0y · Female·Methylamphetamine toxicity

A newborn baby died 8 hours after birth from methylamphetamine toxicity acquired in utero. The mother unknowingly consumed methylamphetamine in the days before labour, likely by drinking from a contaminated bottle at a r…

neonatologypaediatricsmethamphetamine
NSWhospital2018-06-22

Inquest into the death of Jasmine Chiang

0y · Female·Hypoxia resulting from primary idiopathic pulmonary hypertension of the newborn …

Jasmine Chiang died at 7 hours of age from primary idiopathic pulmonary hypertension of the newborn (PPHN), probably complicated by pulmonary haemorrhage. She presented with classic PPHN signs (harlequin appearance, diff…

neonatologypaediatricsdelaypethidine

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.