Deceased
Noah Philip James Sheekey
Demographics
3y, male
Coroner
Coroner Jacinta Heffey
Date of death
2009-01-10
Finding date
2014-11-19
Cause of death
Escherichia Coli sepsis in a low birth weight infant
AI-generated summary
Noah Sheekey, a small-for-gestational-age neonate, died of E. coli sepsis at 3 days old, one day after discharge from hospital. Although his initial condition was reassuring, he was managed on the postnatal ward rather than special care nursery. Critical gaps in care included: lack of paediatric team involvement in discharge decision-making, absence of vital sign monitoring after initial assessment, no pre-discharge paediatric examination, and discharge without paediatric follow-up documentation. The independent expert found that whilst the decision for ward care was initially reasonable, subsequent protocols were inappropriate for an SGA infant. Had Noah remained hospitalised on the evening of 9 January or received closer paediatric supervision, earlier detection of infection symptoms may have enabled earlier intervention, potentially altering outcome. The hospital subsequently implemented substantial protocol changes requiring mandatory paediatric team involvement in all 'qualified' baby discharges.
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·Complications following forceps delivery
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…
0y · Female·Perinatal asphyxia
Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…
0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …
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.