329 results for “delivery”
0y · Female·respiratory failure due to congenital pneumonia with hyaline membrane disease ca…
…genial pneumonia caused by streptococcus pneumoniae. The maternal high vaginal swab taken one week before delivery was positive for streptococcus pneumoniae but this critical result was not properly communicated or under…
55y · Female·Plastic bag suffocation
…and (DSQ) had significant delays in assessment (3-4 months wait) and assessment did not guarantee service delivery due to resource constraints. Her final mental health assessment showed low immediate suicide risk but ack…
0y · Female·Cerebral hypoxia due to placental abruption
…tre availability: the caesarean was classified as category 2 at 2125, upgraded to category 1 at 2130, but delivery did not occur until 2209 (79 minutes after the category 1 decision). Two experts opined the 30+ minute de…
62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia
… intervention to prevent death. Coroner found insufficient effort to secure specialist review and delayed delivery of final X-ray reports contributed to preventable death.
0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…
…gies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged asphyxia during difficult delivery, and massive subgaleal haemorrhage from unsuccessful vacuum extraction. Clinical failures included: inade…
33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury
…on a general orthopaedic ward rather than ICU. Key shortcomings included inconsistent supplemental oxygen delivery despite morphine PCA use, and inadequate recording of urine output—both potentially significant in a high…
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 …
13y · Male·Malignant hyperthermia due to a reaction to an anaesthetic agent administered to…
…e not documented on kitchen whiteboards, and no nurse verification of allergen-free meals occurred before delivery. While medical staff performed appropriately under emergency conditions, institutional failures in allerg…
0y · Female·Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficien…
…dinated. By 5:25pm, obstetric review showed a clearly abnormal CTG pattern warranting emergency caesarean delivery, yet this was not performed until natural delivery occurred at 7:26pm. The coroner found suboptimal anten…
63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…
… home to Bunbury. When platelets were urgently needed on 13 February, the order was not marked urgent and delivery was delayed overnight. Early on 14 February she suffered an intracranial bleed; platelets arrived at 9:50…
31y · Male·accidental overdose of fentanyl
… a common fatal administration method. Security and surveillance gaps at the perimeter fence allowed drug delivery to occur undetected over multiple weeks. The coroner noted this was a low-security rehabilitation facilit…
0y · Male·Complications of birth-related traumatic head injury
…plications of birth-related traumatic head injury. Labour was prolonged in the second stage; instrumental delivery was attempted but abandoned due to a deeply impacted fetal head. Emergency caesarean section was performe…
56y · Male·Multiple head, chest and limb injuries following motor vehicle collision
John Charles Tscherkaskyj, a 56-year-old newspaper delivery driver with 10+ years experience on this route, died in a head-on motor vehicle collision on Gordon River…
0y · Female·Perinatal asphyxia
…es of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6 hours before delivery had compromised foetal wellbeing, though no compromise was detected during labour or antenatally. The neo…
0y · Female·Perinatal asphyxia
…g labour, likely changing labour management decisions. However, an expert obstetrician noted even earlier delivery might not have prevented serious harm due to multiple pre-existing physiological compromises including pl…
24y · Male·Blunt trauma to the head, neck and chest sustained when a forklift toppled onto …
…hed when a Mitsubishi forklift overturned while he was attempting to unload a 1.9-tonne steel pack from a delivery truck parked perpendicular to the factory on a slope of approximately 9.9 degrees on 7 November 2013. The…
39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…
…hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally despite three prior caesarean se…
24y · Male·seizure (epileptic)
Mohammad Nasim Najafi, a 24-year-old Afghan detainee with well-controlled epilepsy, died from a seizure after missing multiple doses of carbamazepine in the days preceding his death. He was held in immigration detention …
Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…
…Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstructed for 20 minutes with inadequate assistance. Jahli Hobbs (breech presentation) died from pla…
Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…
…luded: inadequate informed consent regarding induction necessity and risks; lack of advice about risks of delivery at non-tertiary hospital; obstetrician absent from hospital when Syntocinon commenced (standard practice …
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.