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VIChospital2021-11-08

Finding into death of Baby MNL

0y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia

A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…

obstetricsneonatologysystemcommunicationterbutaline
QLDhomePodcast2021-09-17

Ely-Smith, Zamia

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…

midwiferyobstetricsdiagnosticcommunication
VIC2021-05-24

Finding into death of Melanie Diane Doherty

29y · Female·Mixed Drug Toxicity

A 29-year-old woman died from mixed drug toxicity after being found unresponsive at a residential parenting program. She had complex medical conditions including coproporphyria, epilepsy, and opioid use disorder. Critica…

addiction medicinepsychiatrymedicationcommunicationmethadone
VIChospital2021-03-31

Finding into death of Sarah Louise Rose

40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…

Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyro…

general practiceemergency medicinediagnosticcommunicationthyroxine
QLDhome2021-02-17

T, an eight week old infant - Non-inquest findings

0y · Male·Sudden infant death syndrome category II (SIDS) - accidental asphyxiation due to…

An 8-week-old infant died from SIDS category II, likely due to accidental asphyxiation when the mother fell asleep and slumped forward over him. The infant was born to a mother with a 12-year history of heroin addiction …

neonatologypaediatricssystemcommunicationheroin
QLDhospital2021-01-27

Brown, Tara Matekino - Non-inquest findings

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…

emergency medicineintensive carediagnosticcommunication
VIChospital2020-10-19

Finding into death of BABY FF

2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…

A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 w…

obstetricsneonatologymonitoringcommunicationoxytocin
VIChome2020-08-31

Finding into death of Baby M

0y · Female·Sudden Infant Death Syndrome (SIDS Category II)

A 3-month-old female infant died from Sudden Infant Death Syndrome (SIDS Category II) after co-sleeping with her parents. The death occurred in the context of unsafe sleeping practices despite prior intervention by Child…

paediatricspaediatric surgerycommunicationsystemcannabis
QLDhospital2020-08-26

Baby C - non-inquest findings

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…

neonatologyobstetricsdiagnosticproceduralmorphine
SAhospital2020-08-04

Coroner's Finding: WILLMETT Laura Angela

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 …

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
VIChospital2020-07-02

Finding into death of Cai Wheeler-Trow

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…

obstetricspaediatricsdiagnosticcommunication
VIChospital2020-06-29

Finding into death of Baby AA

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…

neonatologypaediatricsdiagnosticcommunicationbenzyl penicillin
VIChospital2020-05-21

Finding into death of Baby S

Female·Sepsis in the setting of a lotus birth

A premature female neonate born at 36+5 weeks via emergency caesarean section developed sepsis and died at 2 days of age. She had been delivered with lotus birth (cord left attached to placenta) and vaginal seeding (mate…

obstetricspaediatricscommunicationsystembenzylpenicillin
VIChospital2020-03-18

Finding into death of Sommer Bethany Warren

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 …

obstetricsanaesthesiamedicationdiagnosticropivacaine
VIChome2019-12-11

Finding into death of Maddox Garry Wheeler

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 …

neonatologyobstetricscommunicationdelaymethamphetamine
VIChospital2019-11-11

Finding into death of Finn Moser

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…

obstetricsneonatologydiagnosticcommunicationprostaglandin gel
VICcommunity2019-10-30

Finding into death of Sanaya Sahib

1y · Female·Suffocation

Sanaya Sahib, age 14 months, died from suffocation on 9 April 2016. Her mother, Sofina Nikat, deliberately suffocated her and left her body in Darebin Creek. Ms Nikat was experiencing significant social isolation, family…

obstetricspsychiatrysystemdelaymethamphetamine
VIChospital2019-09-26

Finding into death of Tangimama Tavai

35y · Female·Unascertained

A 35-year-old grand multipara with multiple risk factors (BMI >35, smoking, grand multiparity, pregnancy-induced hypertension) presented at 40+4 weeks with absent foetal movements and was induced on Sunday evening. She e…

obstetricsanaesthesiacommunicationsystemoxytocin
VIChospital2019-09-18

Finding into death of Lucia Grace Sefton (Bowlen)

Female·Head injury in the setting of an obstructed labour

A term-destined baby (35 weeks gestation) died from head injuries sustained during delivery. She presented to hospital with suspected preterm labour, was managed conservatively initially, and progressed to spontaneous la…

obstetricspaediatricsproceduralsystemcelestone
NSWhospital2019-07-29

Inquest into the death of Naomi Williams

27y · Female·Septicaemia secondary to Neisseria meningitides infection

Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital sign…

emergency medicinegeneral practicediagnosticcommunicationparacetamol

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