Deceased
Matthew Hutchinson
Demographics
0y, male
Date of death
2002-01-07
Finding date
2005-06-02
Cause of death
cardiogenic shock and neonatal encephalopathy
AI-generated summary
Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical failures included: failure to insert an arterial line early (only placed 12 hours after birth), inadequate blood pressure monitoring before and during hypothermic neuroprotection therapy, failure to assess baseline cardiovascular and metabolic status before commencing cooling therapy, delayed treatment of metabolic acidosis, and incomplete coagulation assessment. These monitoring gaps prevented clinicians from recognizing progressive hypotension and acidosis. The case highlights the need for comprehensive cardiovascular and biochemical monitoring in sick neonates, particularly before experimental therapies. No autopsy was performed, leaving alternative diagnoses (birth trauma, infection, metabolic disorders, congenital heart disease) unexcluded.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease
Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…
29y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…
A 29-day-old neonate died from severe neonatal encephalopathy following birth asphyxia. The infant was born after prolonged induction and protracted second-stage labour at Lyell McEwin Hospital, followed by instrumental …
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