171 results
4y · Male·perinatal asphyxia
Bradley Piper was born prematurely (34 weeks) at Kilmore Hospital on 22 January 2007 and died from perinatal asphyxia. Expert evidence established that the hypoxic-ischaemic insult occurred before the last hour of labour…
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…
0y · Male·Intrapartum hypoxia due to true knot in umbilical cord with cord wrapped three t…
Tyler Reading-Adams died at 95 minutes old from intrapartum hypoxia caused by a true knot in his umbilical cord wrapped three times around his neck. The mother presented at 40 weeks 6 days gestation with spontaneous rupt…
Male·Extreme prematurity
Ty Lacey was born at 24.2 weeks gestation with Twin to Twin Transfer Syndrome (TTTS) after his co-twin died in utero. His parents explicitly requested full resuscitation and transfer to Sydney. When Mrs Lacey laboured at…
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·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…
4y · Male·Sudden Infant Death Syndrome (Category 2)
A 4-month-old infant died of Sudden Infant Death Syndrome (Category 2), unexplained despite complete autopsy investigation. The infant had undiagnosed recurring respiratory issues (suspected reactive airways disease or a…
0y · Unknown·Sudden Infant Death Syndrome (SIDS Category 2)
Baby J, a 5-month-old infant with recent bronchiolitis diagnosis, died of Sudden Infant Death Syndrome (SIDS Category 2) while sharing a bed with his mother. The infant was propped on a pillow on his side in a bed with m…
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…
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…
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…
29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…
Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely cephalosporin-triggered) with car…
0y · Female·Perinatal asphyxia
Summer Elizabeth Rose Niehoff died from perinatal asphyxia hours after vaginal birth following a prolonged labour in hospital. The coroner found multiple clinically preventable failures: escalation of oxytocin augmentati…
14y · Female·Neisseria meningitidis infection (meningococcal septicaemia)
A 14-year-old girl presented to Gosford Hospital Emergency Department on 4 December 2007 with high fever (40°C), headache, vomiting, myalgia, and haemodynamic instability (hypotension, tachycardia, tachypnoea)—all signs …
0y · Female·Perinatal asphyxia
Poppy Louise Habgood was born at 0100 hours on 10 July 2008 by emergency caesarean section at 42 weeks gestation, weighing 3968g. She was born severely asphyxiated with a heart rate of 60bpm and died at 0126 hours despit…
34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …
A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…
0y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart ra…
0y · Female·Mechanical asphyxia due to or as a consequence of overlaying while bed-sharing d…
Bela Heidrich, a newborn, died from mechanical asphyxia due to overlaying while bed-sharing with her mother during breastfeeding in hospital. The mother, Zelia, was exhausted after labour and fell asleep while breastfeed…
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