Coronial

67 results for foetal resuscitation

SAhospital2002-09-18

Coroner's Finding: McPHAIL Matthew Anthony

0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…

…ween 9.30-9.40 pm. Delivery was by forceps. The child was pale, cyanotic and unresponsive at delivery. Resuscitation was attempted but the infant exhibited no spontaneous vital signs—no cardiac output, no brain function…

obstetricsgeneral practicedelayoxytocin
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
VIChospital2025-02-18

Finding into death of Tasman Murray Tribe

0y · Male·Complications of birth-related traumatic head injury

…volvement and anesthetic support. Tasman was born in severe asphyxia with poor Apgar scores, requiring resuscitation and intensive care. He suffered extensive hypoxic-ischemic brain injury and multiorgan dysfunction. Th…

obstetricsneonatologyoxytocin
VIChome2024

Finding into death of Baby E

1y · Female·Neonatal pneumonia, meconium aspiration and chorioamnionitis secondary to prolon…

…ls). The coroner found the death preventable: hospital birth would have enabled cardiotocography to detect foetal distress, prompt intervention, GBS screening with antibiotics, and immediate neonatal resuscitation. Even …

obstetricsneonatologydiagnosticsystem
VIChospital2019-09-18

Finding into death of Lucia Grace Sefton (Bowlen)

Female·Head injury in the setting of an obstructed labour

…oeuvres by midwifery staff. The baby was born severely compromised and died shortly after unsuccessful resuscitation. The pathologist concluded head injuries caused death, likely from the disimpaction process. Clinical …

obstetricspaediatricsproceduralsystemcelestone
QLDhomePodcast2021-09-17

Ely-Smith, Zamia

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

…d immediate ambulance call and hospital transfer per guidelines, not delayed escalation; (4) paramedic resuscitation would likely have been earlier and more effective than midwife-only care; (5) falsification of medical…

midwiferyobstetricsdiagnosticcommunication
SAhospital2014-11-14

Coroner's Finding: KEY George Darcy

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

…igns. The CTG tracing was faxed late (23 minutes) to the obstetrician's rooms, delaying his recognition of foetal distress. Though Dr A. attended when urgently called, caesarean section was delayed approximately 60 minut…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
QLDhospital2012-09-28

Davies, Mia

0y · Female·Peripartum hypoxia

Mia Davies died from peripartum hypoxia after a prolonged and poorly managed labour at Royal Brisbane and Women's Hospital. She had been diagnosed with multiple congenital anomalies (atrioventricular septal defect, oesop…

obstetricsmidwiferydiagnosticcommunicationoxytocin
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 mother was not diagnosed with gestational diabetes dur…

anaesthesiaforensic medicinediagnosticsystembenzyl penicillin
VIChospital2025-02-20

Finding into death of Mia Rose Iskander

0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…

…failures and inadequate senior involvement contributed to management deficiencies, though the overwhelming foetal infection may not have been preventable despite earlier delivery.

obstetricsneonatologydiagnosticdelayamoxicillin
WAhospital2023-07-07

Inquest into the Death of Ashlee Jade REINDL

0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…

Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…

obstetricsmidwiferydiagnosticcommunicationoxytocin
VIChospital2014-08-12

Finding into death of Baby Paula Victoria OShea

0y · Female·Intra-uterine hypoxia

…ly asphyxiated at birth with Apgar scores of 1, 0, 0, 0 at successive time intervals, and died despite resuscitation. The coroner found no breach of clinical care, concluding that while earlier CTG interpretation might …

obstetricsmidwiferydiagnosticoxytocin
NSWhospital2018-06-22

Inquest into the death of Manusiu Amone

0y · Female·ischaemic hypoxic encephalopathy secondary to factors associated with the sudden…

…itially suspected. At 145 minutes of life, she developed gasping respirations and failed to respond to resuscitation. Key clinical lessons: (1) pethidine administration at 9:25pm, approximately 35 minutes before deliver…

obstetricsneonatologymedicationcommunicationpethidine
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
VIChospital2008-08-15

Finding into death of William Grant Keays

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

…labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation to achieve cardiac output. He died 7 hours later from hypoxic brain injury due to intra-uterine asphyx…

obstetricsneonatologycommunicationdelayoxytocin
VIChospital2012-07-16

Finding into death of Dishita Madamshetty

0y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…

…oamnionitis. The baby presented in poor condition at delivery with thick meconium present and required resuscitation. Critical clinical lessons include: (1) inadequate CTG monitoring before induction—the abnormal trace …

obstetricsneonatologydiagnosticcommunication
SAhospital2023-06-30

Coroner's Finding: Vanin, Levi Shane

29y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…

…in Hospital, followed by instrumental delivery. Initial concerns about delayed delivery and inadequate resuscitation were addressed through expert review. Joint expert opinion (obstetrics professors MacLennan and Pepper…

obstetricsneonatologydinoprostone
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
QLDhome2015-03-23

R, aged one day - Non-inquest findings

0y · Female·meconium aspiration

… an inappropriate surface; and promptly contact emergency services. The midwife had no formal neonatal resuscitation training. AHPRA investigation found care significantly below professional standards. The coroner noted…

midwiferyneonatologydiagnosticprocedural
QLDhospital2017-06-28

Langley, Archer

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

Archer Langley died at age 1 hour from severe amniotic fluid aspiration following delivery by emergency caesarean section for obstructed labour. His mother's labour was prolonged and difficult, but critical delays occurr…

obstetricsneonatologydiagnosticcommunicationprostin

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