Deceased
Dean Smith
Demographics
1y, male
Coroner
Coroner Jacinta Heffey
Date of death
2008-09-26
Finding date
2012-05-23
Cause of death
Hypoxic ischaemic encephalopathy
AI-generated summary
Dean Smith, a full-term neonate, was born severely asphyxiated after an induced labour managed at Central Gippsland Health Service. He died from hypoxic-ischaemic encephalopathy within 24 hours. The coroner found critical deficiencies in foetal monitoring. Although classified as high-risk (primigravida, post-term, induced labour), continuous electronic foetal monitoring was not applied until syntocinon augmentation was administered. Only intermittent Doppler auscultation was used, which cannot detect subtle distress indicators like loss of short-term variability. Syntocinon was administered without prior normal CTG, potentially causing or exacerbating foetal distress through uterine hyperstimulation. Early continuous CTG monitoring (from 8pm or at least from 2am onwards, and definitely 20 minutes before syntocinon) may have identified foetal compromise, enabling urgent operative delivery potentially resulting in a healthy baby. Documentation errors and non-functioning labour suite clocks complicated timeline reconstruction.
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
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