Finding into death of Sebastian Hewitt
Deceased
Sebastian Hewitt
Demographics
2y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2005-06-03
Finding date
2012-06-22
Cause of death
Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure
AI-generated summary
Sebastian Hewitt, born at 36 weeks gestation following maternal ante-partum haemorrhage and abnormal CTG traces, died from perinatal asphyxia leading to cerebral anoxia and multi-organ failure at 3 days old. Critical clinical lessons emerged regarding neonatal assessment: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat blood gas analysis within 30-60 minutes of delivery. Significant hypoglycaemia (BSL 1.3-1.7 mmol/L) in the first hours of life should prompt immediate intravenous dextrose rather than continued oral feeding. Dr Mel's conservative approach, whilst appropriate for stable infants, was inadequate for this at-risk baby born after acute blood loss. Systems failures in pathology result communication (2.5-hour delays) delayed necessary escalation and NETS transfer. The case demonstrates importance of integrating clinical signs, objective investigations, and appropriate clinical deterioration responses rather than optimistic reassessment despite objective warning signs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- inadequate investigation of persistent pallor
- inadequate management of severe hypoglycaemia
- inappropriate response to abnormal cord blood gas results
- failure to escalate care appropriately
- delayed availability of arterial blood gas results to treating team
- failure to arrange NETS transfer earlier
- foetal-maternal haemorrhage unconfirmed at birth
Coroner's recommendations
- Install dedicated fax line in Special Care Nursery for receipt of pathology results
- Purchase point-of-care testing devices (iStat) to obtain blood gas results within 15 minutes
- Develop and implement NETS Transfer Pack and education about NETS availability
- Purchase cardiac monitors with blood pressure measurement capability for all four limbs
- Implement systematic practice of taking additional steps to ensure clinicians are aware of aberrant pathology results
- Enhance communication systems between pathology providers and clinical units regarding abnormal results
- Ensure repeat blood gas analysis is performed 30-60 minutes after delivery if initial results are abnormal
Full text
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.