Coronial

42 results for birth asphyxia

VIChospital2013-07-02

Finding into death of Bradley Piper

4y · Male·perinatal asphyxia

…dley 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, b…

obstetricsneonatologycommunicationdelaypethidine
QLDhospital2014-12-09

Baby A - Non-inquest findings

Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome

…espite multiple indications (pre-eclampsia, suspicious admission CTG, meconium-stained liquor risk); water birth was allowed despite being contraindicated in severe pre-eclampsia; and the caesarean section was delayed 9…

obstetricsmidwiferydiagnosticprocedurallabetalol
QLDhome2012-06-29

Baby M

2y · Male·Hypoxic-ischaemic encephalopathy

Baby M was born at term (35-38 weeks gestation) into a toilet bowl at home on 27 November 2008 after an unrecognised pregnancy. The mother reported no awareness of pregnancy despite a positive pregnancy test earlier in t…

neonatologyparamedicinediagnosticdelay
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. …

obstetricsneonatologysystemcommunicationterbutaline
SAhospital2014-11-14

Coroner's Finding: KEY George Darcy

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…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
NThospital2009-04-09

Inquest into the death of Georgia Rae Tilmouth

0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…

…Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contributed to he…

obstetricsmidwiferydiagnosticcommunicationoxytocin
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…

…sfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She died 9 hours 43 minutes after birth from combined hypoxic-ischaemic encephalopathy and E. coli sepsis secondary to chorioamnionitis. Critical …

obstetricsneonatologycommunicationsystemmagnesium sulphate
VIChospital2012-01-31

Finding into death of Summer Elizabeth Rose Niehoff

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…

anaesthesiamidwiferycommunicationdiagnosticoxytocin
VIChospital2017-01-24

Finding into death of Baby XY

0y · Female·Perinatal asphyxia

Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the …

anaesthesiaforensic medicinediagnosticsystembenzyl penicillin
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

… of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay in an adult bed with excessive bedding; Infant P (1 month) died in similar circ…

paediatricspsychiatrydiagnosticcommunicationmethadone
SAhome2010-09-30

Coroner's Finding: Infant Co-Sleeping

Female·Multiple: undetermined consistent with overlaying (Naomi Kade); undetermined pos…

This inquest examined five infant deaths (aged 1 month to 10 months) occurring between July 2007 and November 2008, all involving co-sleeping with adults. Deaths were attributed to undetermined causes, possible overlayin…

forensic medicinepaediatricsamitriptyline
VIChospital2012-06-22

Finding into death of Sebastian Hewitt

2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure

…6 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 clinical lessons emerged regar…

obstetricspaediatricsdiagnosticdelay
VIChospital2023-10-20

Finding into death of Vanessa Li

0y · Female·subgaleal haematoma complicating an obstructed labour

…PIPER retrieval team during handover. The SGH was not identified until 7.30am, approximately 6 hours after birth. Earlier recognition and aggressive blood pressure support may have prevented deterioration, though outcom…

obstetricsneonatologycommunicationdiagnosticoxytocin
NSWhome2018-11-14

Inquest into the death of Jaxon McGrorey-Smith

0y · Male·neonatal encephalopathy due to perinatal compromise

…rolonged labour. He developed seizures and signs of hypoxic-ischaemic encephalopathy (HIE) within hours of birth, with MRI imaging confirming severe bilateral brain injury. After detailed discussions with the parents re…

neonatologyneurologyoxytocin
VIChospital2008-08-15

Finding into death of William Grant Keays

Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…

…scitation to achieve cardiac output. He died 7 hours later from hypoxic brain injury due to intra-uterine asphyxia. Clinical issues included: inadequate informed consent regarding induction necessity and risks; lack of a…

obstetricsneonatologycommunicationdelayoxytocin
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
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
QLDhome2021-02-17

B, an eleven week old infant - Non-inquest findings

0y · Female·Sudden infant death syndrome or asphyxiation due to co-sleeping or overlaying

…the bed at 6:30am. Autopsy could not conclusively determine cause of death but indicated probable SIDS or asphyxiation from co-sleeping/overlay. Clinical lessons include: recognising SIDS risk factors (co-sleeping, paren…

paediatricspathologysystemcommunicationcannabis
SAhome2008-06-25

Coroner's Finding: Baby Safe Sleeping Practices

Zara Schupelius: suffocation; Callum Smith: undetermined; Jake Hackett: suffocat…

…s, and heavy bedding. Key clinical lessons: safe sleeping environments are critical for preventing infant asphyxiation; firm mattresses, back sleeping position, minimal bedding, and individual cots are essential; unsafe …

forensic medicinepaediatricssystemcommunication
VIChospital2021-11-18

Finding into death of Pippa May Griffiths

0y · Female·Neonatal death in the setting of meconium aspiration

A term neonate died from meconium aspiration three hours after spontaneous labour onset. The mother had presented to hospital the previous day with decreased foetal movements and was discharged without comprehensive asse…

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