Death of a Baby - Non-inquest findings
Demographics
0y, female
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.
Error types
Drugs involved
Clinical conditions
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
- Future siblings of the baby should receive vitamin K prophylaxis
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