115 results
0y · Female·head injuries
Twin infant died of head injuries inflicted by her mother, a previously well-functioning woman suffering unrecognized postnatal depression during the stressful period of managing unsettled twins with colic and poor weigh…
0y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…
Elsie Coghill, a newborn, died from hypoxic ischaemic encephalopathy due to multiple factors including an underlying lung abnormality from antenatal distress, an undetected apnoeic episode during transfer, and undiagnose…
0y · Female·Perinatal asphyxia
A 10-day-old infant died from perinatal asphyxia after being born in a home birthing pool. The mother entered the pool without a midwife present after spontaneous rupture of membranes during precipitous labour. Critical …
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…
35y · Female·Stab wound to chest penetrating the descending thoracic aorta resulting in catas…
DM, a 35-year-old woman, died from a stab wound to the chest inflicted by her husband during a domestic violence incident on 26 June 2011. The wound penetrated the descending thoracic aorta, causing catastrophic blood lo…
0y · Female·Blunt head trauma from multiple deliberate blows inflicted by father
Ebony Napier, aged 4 months, died from blunt head trauma resulting from multiple deliberate blows inflicted by her father Bradley Napier-Tucker over several weeks. A critical failure occurred when the South Australian ch…
0y · Male·intrapartum hypoxia due to placental abruption
A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home birth, disengaged from hospital when her preferences for birth management (va…
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 · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia
Baby B suffered severe perinatal asphyxia during a planned home birth and died from hypoxic ischaemic encephalopathy. An obstetrician recommended hospital delivery based on the mother's previous unexplained neonatal emer…
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 …
1y · Female·cystic encephalomalacia
Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% ri…
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…
5y · Female·Sudden Infant Death Syndrome Category II
A 5-month-old infant died from Sudden Infant Death Syndrome (SIDS II) after being placed prone to sleep in a portable cot with additional bedding including thick blankets, a foam couch mattress, and rolled blankets to fi…
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…
4y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…
Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner foun…
2y · Male·Severe hypoxic ischaemic encephalopathy (grade 3)
A term two-day-old baby died of severe hypoxic-ischaemic encephalopathy (grade 3) following a home birth on a farm 25km from hospital. The birth was complicated by shoulder dystocia and profound asphyxia. Although expert…
31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…
Michelle Johnson, a 31-year-old pregnant woman at 32 weeks gestation, presented to the Royal Women's Hospital with sudden-onset severe left-sided abdominal pain and hypotension on 21 March 2010. She was assessed by regis…
0y · Male·complications of intrauterine hypoxia
Baby Jacob Hill died from intrauterine hypoxia following an obstructed labour managed at Sunshine Hospital. A 39-week primiparous labour was complicated by deep transverse arrest. After initial assessment suggesting caes…
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