Deceased
R
Demographics
0y, female
Coroner
McDougall
Date of death
2012-03-02
Finding date
2015-03-23
Cause of death
meconium aspiration
AI-generated summary
A full-term female infant (41 weeks 3 days) died from meconium aspiration during a planned home water birth attended by an experienced midwife. The mother had gestational diabetes and a history of macrosomic babies—risk factors for meconium aspiration and difficult delivery. The midwife failed to: conduct adequate risk assessment; obtain informed consent for water birth acknowledging serious risks; provide adequate lighting (used only candles), preventing early detection of meconium in the birthing pool; perform effective neonatal CPR on an inappropriate surface; and promptly contact emergency services. The midwife had no formal neonatal resuscitation training. AHPRA investigation found care significantly below professional standards. The coroner noted preventability was uncertain but identified failures in risk assessment, monitoring, resuscitation technique, and clinical decision-making regarding home birth suitability.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospita…
24y · Female·Head injury from repeated blunt force trauma
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