Deceased
Tate Spencer-Koch
Demographics
female
Date of death
2007-07-16
Finding date
2010-06-04
Cause of death
intra-partum hypoxic event secondary to shoulder dystocia with prolonged foetal entrapment in birth canal
AI-generated summary
Tate Spencer-Koch was delivered via homebirth at 5:40am after her head crowned at 5:20am with shoulder dystocia causing entrapment in the birth canal for approximately 20 minutes. During this period, the foetus remained reliant on placental oxygenation. The post-delivery examination by midwife Lisa Barrett found no detectable mechanical pulse or respirations. However, when ambulance paramedics arrived approximately 8 minutes later, cardiac monitoring detected pulseless electrical activity (PEA) at 15 beats per minute—a weak electrical rhythm without mechanical heart contraction. Resuscitation efforts failed. The coroner determined this PEA constituted a 'sign of life' under the born-alive rule, establishing jurisdiction to investigate the death. The clinical lesson is the critical importance of recognising that shoulder dystocia is a life-threatening obstetric emergency requiring immediate resolution; prolonged entrapment causes hypoxic-asphyxic injury incompatible with neonatal survival, even with subsequent advanced life support.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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…
0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia
A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a …
25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss
A 25-year-old pregnant woman (23 weeks) presented to hospital with sudden left upper quadrant abdominal pain and loss of consciousness. Clinical assessment identified renal colic and gallstones as likely diagnoses. She r…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.