Deceased
Baby M
Demographics
0y, female
Coroner
Coroner Sarah Gebert
Date of death
2022-11-10
Finding date
2025-09-29
Cause of death
Perinatal asphyxia
AI-generated summary
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 hours before delivery had compromised foetal wellbeing, though no compromise was detected during labour or antenatally. The neonatal resuscitation encountered multiple technical difficulties: failed intubation by the junior registrar, then successful intubation by the consultant at 15 minutes of life but without effective ventilation achievement. Clinical lessons include: escalation to senior staff could have been marginally earlier (called at 6 minutes rather than potentially at 1 minute); higher ventilation pressures could have been considered earlier; laryngeal mask airway should be considered after failed intubations; umbilical catheter securement technique requires careful attention to prevent blockage. However, expert review concluded Baby M had very low survivorship likelihood given the severity of her pre-birth compromise and unrelenting ventilation difficulties. Comprehensive neonatal resuscitation training including simulation and video laryngoscopy may help in future similar situations.
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·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…
A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 w…
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