Coronial

28 results for high-risk pregnancy

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
VIChospital2018-10-26

Finding into death of Baby B

1y · Male·Hypoxic-ischaemic encephalopathy and multisystem failure in the setting of extre…

…death was multifactorial. The mother had limited antenatal care despite known methamphetamine use during pregnancy, absent child protection notification, and booking failure by maternity services. The breech presentatio…

obstetricsneonatologydiagnosticsystemmethamphetamine
WAhome2015-06-08

Inquest into the Death of Baby B

0y · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia

…ed to other healthcare staff. The case highlights the necessity for unambiguous written documentation of high-risk pregnancy decisions and mandatory communication protocols between midwifery programs and medical staff t…

obstetricsmidwiferycommunicationsystem
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…

…; he was delivered after an 80-minute delay, en route to hospital. All three deaths were associated with high-risk pregnancies unsuitable for homebirth: macrosomia with shoulder dystocia risk, breech presentation, and t…

obstetricsmidwiferydiagnosticcommunication
VIChome2014-04-08

Finding into death of Thomas Freemantle

2y · Male·Severe hypoxic ischaemic encephalopathy (grade 3)

…opinion suggested outcome might have been identical in hospital, the coroner found that given documented high-risk factors (previous shoulder dystocia, cephalo-pelvic disproportion, postpartum haemorrhage), home birth w…

obstetricsmidwiferycommunicationsystem
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

…vices over 12 months, critical information was not shared between agencies. Court Link identified her as high-risk and attempted referral to a High Risk Team but the referral was never completed before her case closed. …

general practiceobstetricscommunicationsystemmethamphetamine
QLDhome2015-01-29

Daw, Lilly Ella - Non-inquest findings

1y · Female·cystic encephalomalacia

…out documented SIDS counselling or detailed community follow-up, critical clinical information about her high-risk status was not communicated between obstetric, neonatal and paediatric teams. When Lilly presented with …

obstetricspaediatricscommunicationdelay
NSWhospital2024-04-12

Inquest into the death of Everett Carleton

0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …

…tetric and neonatal teams regarding cord transection—the NICU team was unaware, preventing deployment of high-risk resuscitation with emergency blood transfusion; and equipment malfunction (dim laryngoscope light) durin…

obstetricsneonatologycommunicationprocedural
NSWhospital2012-12-11

Ty lacey findings dsc guy

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…

obstetricsneonatologycommunicationsystem
VIChospital2015-07-15

Finding into death of Baby Mabel Windmill

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…

obstetricsanaesthesiadiagnosticmedicationbenzylpenicillin
QLDhospital2014-12-09

Baby A - Non-inquest findings

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…

obstetricsmidwiferydiagnosticprocedurallabetalol
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 eve…

obstetricsanaesthesiacommunicationsystemoxytocin
VIChospital2012-05-23

Finding into death of Dean Smith

1y · Male·Hypoxic ischaemic encephalopathy

…hy within 24 hours. The coroner found critical deficiencies in foetal monitoring. Although classified as high-risk (primigravida, post-term, induced labour), continuous electronic foetal monitoring was not applied until…

obstetricsmidwiferydiagnosticproceduralprostaglandin
TAShospital2015-10-09

Coroner's Finding: Hay, Katrina Maree

35y · Female·Acute right heart failure (cor pulmonale) following intravenous injection of cru…

…cations are unsuitable for intravenous injection and that healthcare workers and agencies should counsel high-risk patients about this lethal practice. This was the second such death involving the deceased's partner.

emergency medicineintensive carealprazolam
VIChome2026-01-06

Finding into death of Michelle Margaret Darragh

32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…

…pt but did not complete a formal family violence risk assessment despite documented evidence of multiple high-risk factors including separation, substance abuse, access to weapons, and delusional beliefs about infidelit…

psychiatryemergency medicinediagnosticcommunicationsertraline
WAhome2015-06-08

Inquest into the Death of Baby P

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…

obstetricsmidwiferycommunicationdelay
QLDhospital2012-09-28

Davies, Mia

0y · Female·Peripartum hypoxia

…m fetal blood sampling when indicated, and suboptimal consultant review and supervision of this complex, high-risk case.

obstetricsmidwiferydiagnosticcommunicationoxytocin
WAhome

Inquest into the Death of Baby AM

0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture

…al birth with early assessment, timely CTG monitoring, or earlier specialised review at Bunbury Hospital High-Risk Clinic.

obstetricsmidwiferydiagnosticcommunication
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

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.…

obstetricsneonatologycommunicationsystemmagnesium sulphate
SAhospital2014-11-14

Coroner's Finding: KEY George Darcy

0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…

…ions and delayed obstetric intervention. The infant was delivered at term after induction for post-dates pregnancy. During labour, syntocinon infusion was increased to 120 ml/hour without adequate clinical oversight by …

obstetricsanaesthesiadiagnosticcommunicationoxytocin

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