Coronial

39 results for foetal asphyxia

VIChospital2012-07-16

Finding into death of Dishita Madamshetty

<1y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…

…ack of awareness of CTG monitoring guidelines among midwifery staff. The coroner found failure to increase foetal monitoring from 27 August or proceed to delivery within 48 hours likely contributed to the death. Better c…

obstetricsneonatologydiagnosticcommunication
SAhospital2008-05-23

Coroner's Finding: KROL Riley

<1y · Male·hypoxic ischaemic encephalopathy

…y or requested to perform general anaesthesia, delivery could have been significantly expedited. Prolonged foetal hypoxia may have rendered the outcome inevitable, but systemic inadequacies at the non-tertiary hospital c…

obstetricsanaesthesiacommunicationsystemcervedil
VIChospital2014-08-12

Finding into death of Baby Paula Victoria OShea

<1y · Female·Intra-uterine hypoxia

…performed at 1425 hours (approximately 85 minutes later) for failure to progress. Baby Paula was severely asphyxiated at birth with Apgar scores of 1, 0, 0, 0 at successive time intervals, and died despite resuscitation.…

obstetricsmidwiferydiagnosticoxytocin
SAhospital2023-06-30

Coroner's Finding: Vanin, Levi Shane

<1y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…

A 29-day-old neonate died from severe neonatal encephalopathy following birth asphyxia. The infant was born after prolonged induction and protracted second-stage labour at Lyell McEwin Hospita…

obstetricsneonatologydinoprostone
VIChospital2012-01-31

Finding into death of Summer Elizabeth Rose Niehoff

<1y · 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
VIChome2014-04-08

Finding into death of Thomas Freemantle

<1y · Male·Severe hypoxic ischaemic encephalopathy (grade 3)

…ng a home birth on a farm 25km from hospital. The birth was complicated by shoulder dystocia and profound asphyxia. Although expert opinion suggested outcome might have been identical in hospital, the coroner found that …

obstetricsmidwiferycommunicationsystem
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
ACThospital2024-09-11

Inquest Into The Death Of Baby X

<1y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…

…h. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged asphyxia during difficult delivery, and massive subgaleal haemorrhage from unsuccessful vacuum extraction. Clinica…

obstetricsneonatologydiagnosticcommunication
VIChospital2015-06-12

Finding into death of Baby Chloe Lee Kellett

<1y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

…5/7), requiring respiratory support. Necropsy found cerebral hypoxic-ischaemic injury from clinical birth asphyxia, with the insult occurring 6-8 hours before delivery. Clinical concerns: midwives identified multiple CTG…

obstetricspaediatricsdiagnosticcommunicationoxytocin
VIChome2024-11-21

Finding into death of Baby S

<1y · Male·Hypoxic ischaemic encephalopathy in the setting of a breech delivery

A neonate born at home in breech presentation without medical assistance suffered hypoxic ischaemic encephalopathy and died at 7 days old. The mother had been counselled by hospital obstetricians about risks of home bree…

obstetricsemergency medicine
NThospital2009-04-09

Inquest into the death of Georgia Rae Tilmouth

<1y · 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
NSWhospital2018-06-22

Inquest into the death of Manusiu Amone

<1y · Female·ischaemic hypoxic encephalopathy secondary to factors associated with the sudden…

Manusiu Amone died from ischaemic hypoxic encephalopathy secondary to persistent pulmonary hypertension of the newborn (PPHN), not from pethidine toxicity as initially suspected. At 145 minutes of life, she developed gas…

obstetricsneonatologymedicationcommunicationpethidine
QLDhome2015-03-23

R, aged one day - Non-inquest findings

<1y · Female·meconium aspiration

A full-term female infant (41 weeks 3 days) died from meconium aspiration during a planned home water birth attended by an experienced midwife. The mother had gestational diabetes and a history of macrosomic babies—risk …

midwiferyneonatologydiagnosticprocedural
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
VIChospital2023-10-20

Finding into death of Vanessa Li

<1y · Female·subgaleal haematoma complicating an obstructed labour

Vanessa Li, a term infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who wa…

obstetricsneonatologycommunicationdiagnosticoxytocin
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

<1y · 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. She…

obstetricsneonatologycommunicationsystemmagnesium sulphate
SAhospital2014-07-08

Coroner's Finding: SLEEP Aurora Doreen Maureen

<1y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…

Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner foun…

obstetricsmidwiferycommunicationdiagnosticprostaglandin gel
WAhome2015-06-08

Inquest into the Death of Baby P

<1y · 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

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