Deceased
Baby of Alpitaben and Jaykumar Patel
Demographics
0y, unknown
Coroner
Coroner Ingrid Giles
Date of death
2020-06-06
Finding date
2024-12-02
Cause of death
unascertained
AI-generated summary
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was inappropriately triaged as Category 3 (requiring review within 30 minutes) in the Emergency Department when Category 2 (10 minutes) was indicated. Multiple signs of a seriously unwell neonate were documented but not recognised as such. This led to a one-hour delay before paediatric assessment. The infant was subsequently managed appropriately with antibiotics, fluids, and retrieval but deteriorated despite intensive care including intubation and ECMO support. Cause of death was unascertained at autopsy. Key preventable failures included: inadequate triage protocols for neonates, lack of staff education in recognising unwell neonates, failure to schedule planned follow-up visit by home midwives, and communication gaps between staff and family (no interpreter offered).
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·Unascertained
Baby H was born at home on 21 September 2022 following an unassisted birth (freebirth) without medical oversight. The mother had received no antenatal care despite being unaware of the actual gestational age. The baby sh…
0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…
Jordan was born at 25 weeks 4 days gestation in an emergency department following precipitant breech labour with a circumvallate placenta. He received appropriate initial resuscitation but was administered 10 times the p…
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