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QLDhome2012-06-29

Baby M

2y · Male·Hypoxic-ischaemic encephalopathy

Baby M was born at term (35-38 weeks gestation) into a toilet bowl at home on 27 November 2008 after an unrecognised pregnancy. The mother reported no awareness of pregnancy despite a positive pregnancy test earlier in t…

neonatologyparamedicinediagnosticdelay
VIChospital2012-06-22

Finding into death of Sebastian Hewitt

2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure

Sebastian Hewitt, born at 36 weeks gestation following maternal ante-partum haemorrhage and abnormal CTG traces, died from perinatal asphyxia leading to cerebral anoxia and multi-organ failure at 3 days old. Critical cli…

obstetricspaediatricsdiagnosticdelay
SAhome2012-06-06

Coroner's Finding: Home Birthing - SPENCER-KOCH Tate and HOBBS Jahli Jean and KAVANAGH Tully Oliver

Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…

Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstru…

obstetricsmidwiferydiagnosticcommunication
VIChospital2012-05-23

Finding into death of Dean Smith

1y · Male·Hypoxic ischaemic encephalopathy

Dean Smith, a full-term neonate, was born severely asphyxiated after an induced labour managed at Central Gippsland Health Service. He died from hypoxic-ischaemic encephalopathy within 24 hours. The coroner found critica…

obstetricsmidwiferydiagnosticproceduralprostaglandin
WAhospital2012-04-05

Inquest into the Death of Little

0y · Female·perinatal pneumonia in association with meconium aspiration

Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nin…

neonatologygeneral practicediagnosticcommunication
VIChospital2011-06-16

Finding into death of Owen Appleby

0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…

Owen Appleby, born at Portland Hospital after labour induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APG…

obstetricsneonatologydiagnosticdelayprostin gel
QLDhospital2011-04-05

Hoy, Samara Lee

0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration

Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …

obstetricsmidwiferydiagnosticcommunication
SAhospital2009-06-24

Coroner's Finding: LINNELL Sienna Jools

0y · Female·Group B Streptococcus infection

A 7-hour-old neonate died from early-onset Group B Streptococcus (GBS) infection contracted during labour. The mother's GBS screening test at 35-37 weeks gestation was reported negative, and no antibiotic prophylaxis was…

obstetricsgeneral practicesystemcommunication
NThospital2009-04-09

Inquest into the death of Georgia Rae Tilmouth

0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…

Georgia Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contribut…

obstetricsmidwiferydiagnosticcommunicationoxytocin
VIChospital2008-08-15

Finding into death of William Grant Keays

Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…

William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation …

obstetricsneonatologycommunicationdelayoxytocin
QLDhospital

Death of a Baby - Non-inquest findings

0y · Female·Subdural and subarachnoid haemorrhages due to late onset vitamin K deficiency bl…

A 33-day-old exclusively breastfed baby died from subdural and subarachnoid haemorrhages caused by late-onset vitamin K deficiency bleeding (VKDB). The parents, exercising informed choice based on spiritual beliefs, decl…

neonatologypaediatricsdiagnosticphytomenadione

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