0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…
… equipment. Key clinical lessons include: inadequate prenatal care with missed opportunities for earlier induction (pregnancy went 14 days post-due date); failure to admit the mother to hospital when she called with str…
29y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…
…e died from severe neonatal encephalopathy following birth asphyxia. The infant was born after prolonged induction and protracted second-stage labour at Lyell McEwin Hospital, followed by instrumental delivery. Initial …
0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a …
A neonate died shortly after birth from hypoxia due to intrauterine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother at…
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…
0y · Female·Intrapartum asphyxia refractory to postpartum resuscitation due to amniotic flui…
…rean section for fetal distress, caused by intrapartum asphyxia due to meconium aspiration. While labour induction, oxytocin dosing, and emergency surgery were appropriately managed, the coroner identified deficiencies …
25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss
A 25-year-old pregnant woman (23 weeks) presented to hospital with sudden left upper quadrant abdominal pain and loss of consciousness. Clinical assessment identified renal colic and gallstones as likely diagnoses. She r…
80y · Female·Pulmonary Thromboembolism in a woman with Left Femur Fracture
…erred due to theatre overrun. Surgery was rescheduled for 6 July and commenced at 1:00 pm. Shortly after induction, she suffered a massive pulmonary embolism and died at 3:05 pm despite resuscitation attempts. Post-mort…
31y · Male·Complications in association with intestinal volvulus
31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…
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 …
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…
67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…
A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…
5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in…
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…
15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…
Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…
0y · Male·Head injuries (birth trauma) secondary to obstructed labour and fetal macrosomia…
Nixon Martin Tonkin died from head injuries sustained during caesarean delivery for obstructed labour at 38 weeks gestation. The infant's head became deeply impacted in the maternal pelvis after prolonged second-stage la…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surger…
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