Coronial
QLDhospital

Death of a Baby - Non-inquest findings

Demographics

0y, female

Coroner

Clements

Date of death

2011

Cause of death

Subdural and subarachnoid haemorrhages due to late onset vitamin K deficiency bleeding

AI-generated summary

A 33-day-old exclusively breastfed baby died from subdural and subarachnoid haemorrhages caused by late-onset vitamin K deficiency bleeding (VKDB). The parents, exercising informed choice based on spiritual beliefs, declined vitamin K prophylaxis after receiving adequate information about its purpose. The baby presented with lethargy, poor feeding, and vomiting at one month of age, initially misdiagnosed as sepsis. Imaging revealed extensive intracranial bleeding; INR was critically elevated at 10. Despite emergency transfer, ventilation, and treatment with plasma and vitamin K, the baby died. The coroner found no evidence of trauma or non-accidental injury. Clinical lessons include recognising VKDB in exclusively breastfed infants presenting with neurological symptoms between 8 days and 6 months of age, and the importance of reinforcing vitamin K recommendations despite parental refusal.

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

Specialties

neonatologypaediatricsemergency medicineintensive carepathology

Error types

diagnostic

Drugs involved

phytomenadionefresh frozen plasmaadrenalineantibiotics

Clinical conditions

vitamin k deficiency bleedinglate-onset VKDBsubdural haemorrhagesubarachnoid haemorrhagecerebral oedemacoagulopathyintracranial pressure elevation

Procedures

mechanical ventilationCT imagingblood transfusion (fresh frozen plasma)

Contributing factors

  • Parental refusal of vitamin K prophylaxis
  • Exclusive breastfeeding with insufficient vitamin K
  • Delayed recognition of VKDB symptoms
  • Initial misdiagnosis as sepsis

Coroner's recommendations

  1. Future siblings of the baby should receive vitamin K prophylaxis
Full text

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