Coronial
NSW2012-05-15

Grainger ,helen finding 1767 08 2012 05 31 14 40 06 300

29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…

Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely …

general practiceobstetricsproceduralsystemcephalosporin
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
VIChome2014-04-08

Finding into death of Thomas Freemantle

2y · Male·Severe hypoxic ischaemic encephalopathy (grade 3)

A term two-day-old baby died of severe hypoxic-ischaemic encephalopathy (grade 3) following a home birth on a farm 25km from hospital. The birth was complicated by shoulder dystocia and profound asphyxia. Although expert…

obstetricsmidwiferycommunicationsystem
VIChospital2019-09-26

Finding into death of Tangimama Tavai

35y · Female·Unascertained

A 35-year-old grand multipara with multiple risk factors (BMI >35, smoking, grand multiparity, pregnancy-induced hypertension) presented at 40+4 weeks with absent foetal movements and was induced on Sunday eve…

obstetricsanaesthesiacommunicationsystemoxytocin
QLDhome2015-01-29

Daw, Lilly Ella - Non-inquest findings

1y · Female·cystic encephalomalacia

Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% ri…

obstetricspaediatricscommunicationdelay
QLDcommunity2016-07-28

Antonio, Rachel

16y · Female·physical altercation with Robert Paul Hytch resulting in fatal bodily injury; pr…

…ul Hytch, a 24-year-old lifesaver—21 years her senior. Rachel had planned to confront Hytch about a fake pregnancy she had devised. The coroner found that on the evening of her disappearance, Rachel and Hytch met at Que…

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
VIChome2017-08-28

Finding into death of Tara Sue Love

22y · Female·Sudden Arrhythmic Death Syndrome

…ented multiple times to the Royal Women's Hospital with ECG changes and electrolyte abnormalities during pregnancy. Critical failures occurred in ECG interpretation and escalation: ECG abnormalities documented in Januar…

obstetricscardiologydiagnosticcommunicationlabetalol
VIChospital2015-07-15

Finding into death of Baby Mabel Windmill

0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…

Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…

obstetricsanaesthesiadiagnosticmedicationbenzylpenicillin
SAhome2007-07-12

Coroner's Finding: STEPHEN Esther Ruth

Female·hypoxic-ischaemic encephalopathy due to intrapartum hypoxia due to delayed deliv…

A 54-hour-old neonate died of hypoxic-ischaemic encephalopathy following a planned home birth of twins. The second twin experienced a prolonged delay in delivery (over 60 minutes) during which foetal heart rate decelerat…

obstetricsmidwifery
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
TAShospital2015-10-09

Coroner's Finding: Hay, Katrina Maree

35y · Female·Acute right heart failure (cor pulmonale) following intravenous injection of cru…

A 35-year-old woman with chronic hepatitis C and long-standing intravenous drug use died from acute right heart failure (cor pulmonale) following injection of crushed Xanax tablets. She presented to hospital with cardiog…

emergency medicineintensive carealprazolam
VIChome2026-01-06

Finding into death of Michelle Margaret Darragh

32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…

Michelle Darragh, a 32-year-old social worker, was fatally stabbed by her former partner Benjamin Coman on 9 October 2021. She was pregnant with their third child. The relationship involved progressive coercive control, …

psychiatryemergency medicinediagnosticcommunicationsertraline
ACThome2019-07-31

Inquest into the death of Cheyse Williams-Empson

3y · Male·unascertained

…in his bassinet with a blanket covering his mouth and face. His mother had ongoing heroin use throughout pregnancy and postnatally, concealed from support services through missed urinalysis appointments and provision of…

neonatologyforensic medicinecommunicationsystemheroin
VIChospital2018-09-27

Finding into death of Elizabeth Mary Gorman

35y · Female·Pulmonary thromboembolus and pulmonary infarction

A 35-year-old woman at 11 weeks gestation presented to Royal Women's Hospital Emergency Care on 3 September 2012 with chest and rib pain following severe vomiting. Dr M., a junior resident working alone overnight, assess…

emergency medicineobstetricsdiagnosticcommunicationoxycodone
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…

general practiceobstetricscommunicationsystemmethamphetamine
NSWcommunity2017-06-09

Inquest into the disappearance and suspected death of Katherine ACKLING-BRYEN

37y · Female·open finding - undetermined

…herapy or strong therapeutic relationship established. She stopped psychiatric medication in 2015 during pregnancy and did not resume it after a subsequent miscarriage in November 2015. On the morning of disappearance, …

psychiatrygeneral practicesystemcommunicationanti-psychotic medication
VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

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

Joseph Thurgood-Gates died at 5 days old from global cerebral hypoxic injury due to uterine rupture during labour. The death was preventable. His mother, Ms Thurgood, had two prior caesarean sections and refused hospital…

obstetricsmidwiferydiagnosticcommunication
VIChospital2022-09-30

Finding into death of Baby RMI

0y · Male·Perinatal hypoxia

…al hypoxia, with timing of injury 3-5 days before delivery. The mother had multiple presentations during pregnancy with reduced foetal movements, and investigations including CTGs and ultrasounds were performed. Clinica…

obstetricsneonatologycommunicationsystemintrathecal morphine
NThospital2024-12-06

Inquest into the death of Baby G

0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…

…he coroner found that non-invasive prenatal testing (NIPT) should have been offered to his mother during pregnancy; detection would have enabled planning and support. Baby G's parents, isolated from community supports w…

neonatologypaediatricsdiagnosticsystem

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