Coronial

54 results for foetal distress

VIChospital2012-06-22

Finding into death of Sebastian Hewitt

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

…: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat blood gas analysis within 30-60 minutes of delivery. Significant hypoglyc…

obstetricspaediatricsdiagnosticdelay
VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…

…iculate risks, supported home birth plans despite clinical concerns, and delayed transfer to hospital when foetal bradycardia developed during labour. The bradycardia persisted for over 40 minutes before hospital transfe…

obstetricsmidwiferydiagnosticcommunication
VIChospital2008-08-15

Finding into death of William Grant Keays

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

William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minute…

obstetricsneonatologycommunicationdelayoxytocin
SAhospital2008-05-23

Coroner's Finding: KROL Riley

0y · 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
QLDhospital2017-06-28

Langley, Archer

0y · Male·Amniotic fluid aspiration (severe); with contribution from thin umbilical cord a…

…ed only the CTG in isolation, without full clinical assessment. The consultant was absent due to personal distress and unavailable despite the high-risk nature of the case. An 85-minute delay occurred between decision an…

obstetricsneonatologydiagnosticcommunicationprostin
QLDhomePodcast2021-09-17

Ely-Smith, Zamia

3y · Female·Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vagi…

Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospita…

midwiferyobstetricsdiagnosticcommunication
VIChospital2014-02-24

Finding into death of Baby Jacob Hill

0y · Male·complications of intrauterine hypoxia

Baby Jacob Hill died from intrauterine hypoxia following an obstructed labour managed at Sunshine Hospital. A 39-week primiparous labour was complicated by deep transverse arrest. After initial assessment suggesting caes…

obstetricspaediatricscommunicationdelaypethidine
SAhospital2001-07-13

Coroner's Finding: TRIMBOLI Jayden Tyler

0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia

Jayden Tyler Trimboli, aged 6 days, died from hypoxic-ischaemic encephalopathy caused by a prolonged fetal bradycardia episode between 11:10pm and 11:50pm on 18 September 1998. The critical failure was that the cardiotoc…

obstetricsmidwiferycommunicationsystemprostaglandin gel
VIChospital2014-08-12

Finding into death of Baby Paula Victoria OShea

0y · Female·Intra-uterine hypoxia

Baby Paula O'Shea was born at Sandringham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detecti…

obstetricsmidwiferydiagnosticoxytocin
VIChospital2022-07-28

Finding into death of H C

6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia

… perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons include: (1) continuous CTG monitoring should have been initiated immediately on ar…

obstetricsneonatologydiagnosticcommunication
QLDhospital2017-06-09

Baby L - Non-inquest findings

0y · Female·Group B Streptococcus meningitis and sepsis

…d sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm), and neonatal fever (39.5°C at birth). Despite these signs suggestive of chorioa…

obstetricsneonatologycommunicationdiagnostic
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite special…

psychiatrypaediatricssystemdelay
NSWhospital2024-04-12

Inquest into the death of Everett Carleton

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

Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …

obstetricsneonatologycommunicationprocedural
VIChospital2012-07-16

Finding into death of Dishita Madamshetty

0y · 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
WAhospital2005-12-09

Inquest into the Death of Laura Marguerite Sinclair

31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…

…ed with amniotic fluid embolism (AFE) and uterine hypotonia. She underwent emergency caesarean section for foetal distress at Peel Health Campus, experiencing heavy blood loss (estimated 1500ml). Although initially stabl…

obstetricsanaesthesiadiagnosticcommunicationpethidine
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. Labour progres…

obstetricsneonatologysystemcommunicationterbutaline
NSWhospital2010-07-22

Finding helanisirianni257 08 dscmitchell

Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…

…orrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extraction procedure itself was appropriately performed. However, critical failures in clinic…

obstetricsmidwiferydiagnosticcommunication
QLDhospital2009-10-07

Hildebrandt, Talisha

Female·meconium aspiration

Talisha Hildebrandt was stillborn at Ayr Hospital on 7 January 2007 due to meconium aspiration. The pregnancy was low-risk and managed appropriately. A CTG monitor showed concerning fetal heart rate changes, prompting ur…

obstetricsmidwifery
QLDhospital2012-10-25

Paudel, Preston

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 …

obstetricsmidwiferydiagnosticcommunicationoxytocin
QLDhome2008-09-19

12 year old boy at Kowanyama

12y · Male·Suicide by hanging

… of suspected child sexual abuse and arranged placement with a third party within days. The boy expressed distress about the move and was allowed to return to his original home that evening, where he died. The coroner fo…

paediatricspsychiatrydiagnosticsystem

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