122 results
0y · Female·Head injury
Lily Grace Arbuckle, a 9-week-old infant, died from head injury sustained when her mother placed her on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and …
1y · Female·Neonatal pneumonia, meconium aspiration and chorioamnionitis secondary to prolon…
Baby E died at home one day after birth at 40+ weeks gestation following a prolonged labour in a hired plastic birthing pool. The mother had no antenatal care, no midwifery support, and her Group B Streptococcus status w…
0y · 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…
0y · Female·Sudden infant death syndrome (SIDS) category 2
Baby A, born on 6 August 2018 to a mother in remand custody at Dame Phyllis Frost Centre, died of SIDS category 2 on 18 August 2018 aged 12 days. She was born with neonatal abstinence syndrome due to maternal methadone u…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…
3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…
Baby R, born at 38 weeks gestation to a mother with previous pregnancy losses, was small-for-gestational-age (SGA, 10th centile). The mother was appropriately excluded from the hospital-supported home birth program due t…
6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia
HC was a neonate who died at 6 days old from global cerebral ischaemia secondary to perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons …
34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…
Melissa Gaultier, 34 years old, was discharged from Latrobe Regional Hospital's psychiatric ward (Flynn Unit) less than 24 hours after admission on 13 April 2017, despite comprehensive warnings from Monash Health that sh…
0y · Male·global hypoxic ischaemic encephalopathy
A term breech baby was born at Launceston General Hospital following a traumatic vaginal delivery with instrumental assistance after failed initial extraction attempts. The infant suffered severe hypoxic-ischaemic enceph…
0y · Male·Pneumonia in the setting of malnutrition
Baby A, born at home without medical assistance, died at 19 days old from pneumonia complicated by severe malnutrition and dehydration. He weighed 2.87kg at autopsy, far below his reported 4kg birth weight. He had diffic…
3y · Female·Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vagi…
Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospita…
24y · Female·Head injury from repeated blunt force trauma
A 24-year-old woman was fatally assaulted by her intimate partner after a period of escalating domestic and family violence. The perpetrator had a documented history of violent DFV across multiple relationships, with pri…
0y · 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…
0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia
A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a …
0y · Male·Head injury in the setting of labour
Baby Cai Wheeler-Trow was born at 36 weeks and 2 days following a failed instrumental delivery and emergency caesarean section. He developed a skull fracture and subgaleal haemorrhage, presenting with clinical deteriorat…
0y · Female·Disseminated Herpes Simplex Virus (HSV 1)
An 11-day-old neonate died from disseminated HSV-1 infection acquired perinatally. She presented with sepsis-like symptoms including lethargy, poor feeding, fever and respiratory signs. Clinical management was appropriat…
18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…
An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …
0y · Male·Unascertained
A 10-week-old boy born at 35 weeks gestation was found asleep on his mother's chest while she was asleep on a couch and died from an unascertained cause. Post-mortem toxicology detected methamphetamine and cannabis; the …
1y · Male·Head injury in the setting of labour
Finn Moser was a one-day-old neonate who died from head injury sustained during labour and delivery at the Royal Women's Hospital. He was born to a mother with dichorionic diamniotic twins, induced at 36 weeks due to pre…
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