Deceased
Jordan Thomas Alexander McDonald
Demographics
0y, male
Coroner
Coroner Dimitra Dubrow
Date of death
2022-04-19
Finding date
2025-08-13
Cause of death
complications of extreme prematurity in the setting of precipitant premature breech labour and a circumvallate placental membrane insertion
AI-generated summary
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 prescribed morphine dose due to calculation error during a time-critical retrieval scenario. Although this was a serious medication error, the expert evidence concluded the morphine was unlikely to have contributed to death, as Jordan was mechanically ventilated and his deterioration preceded the morphine administration. Jordan's death resulted from complications of extreme prematurity combined with being born outside a tertiary centre without adequate antenatal steroids. Clinical lessons include: recognising early signs of cardiovascular compromise (persistent tachycardia, metabolic acidosis) and more aggressive early fluid resuscitation; ensuring drug calculation tools are accessible even during sterile procedures; and the critical importance of delivery in tertiary maternity centres for extremely premature infants.
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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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…
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