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VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

<1y · 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…

neonatologyobstetricsmedicationdiagnosticmorphine
VIChospital2024-12-02

Finding into death of Baby Patel

<1y · Unknown·unascertained

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…

neonatologypaediatricsdiagnosticcommunicationcefotaxime
VIChospital2023-10-20

Finding into death of Vanessa Li

<1y · Female·subgaleal haematoma complicating an obstructed labour

Vanessa Li, a term infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who wa…

obstetricsneonatologycommunicationdiagnosticoxytocin
QLDhospital2020-08-26

Baby C - non-inquest findings

<1y · Male·meconium aspiration syndrome complicated by persistent pulmonary hypertension

Baby C was born at 41 weeks and 2 days covered in thick meconium with respiratory distress. Key clinical failures included: (1) failure to respond to mother's request for induction at term+6 days; (2) failure to investig…

neonatologyobstetricsdiagnosticproceduralmorphine
TAShospital2018-08-31

Coroner's Finding: Oosterloo, Jane

63y · Female·Haemopericardium (pericardial tamponade) caused by perforation of the right vent…

Jane Oosterloo, 63, died from haemopericardium (pericardial tamponade) caused by right ventricular perforation during ultrasound-guided transthoracic pericardiocentesis. She presented with influenza B complicated by myoc…

emergency medicinecardiologyoseltamivir
VIChospital2017-01-24

Finding into death of Baby XY

<1y · Female·Perinatal asphyxia

Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…

anaesthesiaforensic medicinediagnosticsystembenzyl penicillin
QLDhospital2007-12-07

Burgen, Deborah Denise

49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…

Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …

emergency medicinesurgerydiagnosticdelayparacetamol/codeine

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