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Baby M

Deceased

Baby M

Demographics

2y, male

Coroner

Lock

Date of death

2008-11-29

Finding date

2012-06-29

Cause of death

Hypoxic-ischaemic encephalopathy

AI-generated summary

Baby M was born at term (35-38 weeks gestation) into a toilet bowl at home on 27 November 2008 after an unrecognised pregnancy. The mother reported no awareness of pregnancy despite a positive pregnancy test earlier in the pregnancy that she denied. Baby M remained in the toilet for approximately 5 minutes before retrieval. Resuscitation commenced at scene around 15-20 minutes after delivery. Despite advanced life support, Baby M suffered irreversible hypoxic-ischaemic encephalopathy from prolonged oxygen deprivation and aspiration, and died on 29 November 2008. The clinical lesson is that unrecognised pregnancy can occur even with clinical contact; healthcare providers should maintain suspicion for pregnancy in women of reproductive age presenting with abdominal pain, despite reported periods or recent surgery under general anaesthesia. Early recognition and appropriate emergency response to perinatal events are critical.

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

Specialties

neonatologyparamedicineemergency medicineintensive careobstetrics

Error types

diagnosticdelay

Clinical conditions

hypoxic-ischaemic encephalopathybronchopneumoniaperinatal asphyxiaunrecognised pregnancy

Procedures

intubationcardiac compressionsmechanical ventilationlife support

Contributing factors

  • unrecognised pregnancy
  • delivery into toilet bowl
  • prolonged time in toilet before retrieval (approximately 5-10 minutes)
  • delay in commencement of resuscitation (15-20 minutes after delivery)
  • aspiration of toilet water
  • bronchopneumonia
Full text

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