Coronial
VIChospital

Finding into death of Jordan Thomas Alexander McDonald

Deceased

Jordan Thomas Alexander McDonald

Demographics

<1y, male

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.

Specialties

neonatologyobstetricsemergency medicinepaediatricsretrieval medicine

Error types

medicationdiagnostic

Drugs involved

morphinesurfactantdobutaminenaloxoneantenatal steroidsbroad-spectrum antibiotics

Clinical conditions

extreme prematurityrespiratory distress syndromecardiovascular instabilitymetabolic acidosispersistent pulmonary hypertension of the newborn (potential)breech presentationcircumvallate placentaopioid overdose (10-fold error)hypoglycaemiahypotension

Procedures

mechanical ventilationintubationumbilical line insertionsurfactant administrationfluid bolus resuscitationblood transfusion

Contributing factors

  • extreme prematurity at 25 weeks 4 days gestation
  • delivery in emergency department rather than tertiary maternity centre
  • absence of adequate antenatal steroid cover
  • breech presentation
  • circumvallate placental membrane insertion
  • cardiovascular instability not recognised early enough
  • delayed aggressive fluid resuscitation
  • morphine dose error
  • difficult vascular access in first hour of life

Coroner's recommendations

  1. PIPER to develop a Medication Management Procedure specifically addressing challenges of the retrieval environment and situations where team members are scrubbed for sterile procedures, ensuring drug calculation tools remain accessible
  2. Ensure relevant clinicians are notified of impending presentations to the emergency department with appropriate recording of calls
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