71 results
0y · Female·Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficien…
Emma, born 26 July 2011, developed severe hypoxic-ischaemic encephalopathy associated with chronic placental insufficiency and died at 4 days old. Her mother reported reduced foetal movements after 34 weeks' gestation, b…
0y · 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…
0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…
Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She…
0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…
5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…
0y · Male·Group B Streptococcal infection and meconium aspiration with early bronchopneumo…
A newborn died of Group B Streptococcal (GBS) infection and meconium aspiration bronchopneumonia less than three hours after planned home birth. The infant was born to a woman with prior traumatic hospital birth who had …
0y · Female·meconium aspiration
A full-term female infant (41 weeks 3 days) died from meconium aspiration during a planned home water birth attended by an experienced midwife. The mother had gestational diabetes and a history of macrosomic babies—risk …
Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome
A full-term baby born at 39 weeks died from hypoxic-ischaemic encephalopathy due to meconium aspiration. Critical failures in fetal monitoring were identified: the admission CTG was abnormal but not recognised as such by…
3y · Male·Escherichia Coli sepsis in a low birth weight infant
Noah Sheekey, a small-for-gestational-age neonate, died of E. coli sepsis at 3 days old, one day after discharge from hospital. Although his initial condition was reassuring, he was managed on the postnatal ward rather t…
0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…
George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…
0y · Female·Sepsis
Baby Lily Irwin died of sepsis caused by ascending bacterial infection (Staphylococcus aureus) that developed after spontaneous rupture of maternal membranes 48 hours prior to delivery. The infection caused chorioamnioni…
0y · Female·Intra-uterine hypoxia
Baby Paula O'Shea was born at Sandringham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detecti…
0y · Male·Complications of small bowel obstruction due to post operative adhesions
Marcus Charles, a 3-month-old neonate, died from small bowel obstruction due to postoperative adhesions following earlier surgical repair of oesophageal atresia and duodenal atresia. On 4 November 2006, paramedics attend…
0y · Female·Cerebral hypoxia due to placental abruption
Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pat…
0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…
Joseph Thurgood-Gates died at 5 days old from global cerebral hypoxic injury due to uterine rupture during labour. The death was preventable. His mother, Ms Thurgood, had two prior caesarean sections and refused hospital…
Male·Global hypoxic-ischaemic encephalopathy
Preston Paudel, born at 37 weeks gestation after meconium-stained labour with syntocinon augmentation, was delivered severely compromised with Apgar scores of 1-1-1 and died of hypoxic-ischaemic encephalopathy. Multiple …
0y · Female·Peripartum hypoxia
Mia Davies died from peripartum hypoxia after a prolonged and poorly managed labour at Royal Brisbane and Women's Hospital. She had been diagnosed with multiple congenital anomalies (atrioventricular septal defect, oesop…
0y · Female·acute blood loss due to velamentous insertion of the umbilical cord with likely …
A neonate died from acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa, a rare condition causing vulnerability to catastrophic bleeding. Key clinical lessons include: (1) prenatal…
0y · Female·respiratory failure due to congenital pneumonia with hyaline membrane disease ca…
Trinity Kison, a 21-hour-old neonate born at 35 weeks gestation, died from respiratory failure due to congenial pneumonia caused by streptococcus pneumoniae. The maternal high vaginal swab taken one week before delivery …
0y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…
A full-term neonate born after induction of labour died from hypoxic brain injury secondary to meconium aspiration syndrome and chorioamnionitis. The baby presented in poor condition at delivery with thick meconium prese…
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