107 results
37y · Female·Hypoxic brain injury complicating cardiorespiratory arrest during manual removal…
A 37-year-old primigravida with gestational diabetes was admitted for labour induction at 37 weeks. Following vaginal delivery and delayed placental separation, manual removal of placenta was performed under spinal anaes…
0y · Female·Cerebral hypoxia due to placental abruption
Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pat…
27y · Female·opiate toxicity (fentanyl)
Hayley Fisher, a 27-year-old midwife at King Edward Memorial Hospital, died from accidental opiate toxicity after injecting a fatal quantity of fentanyl she obtained from a patient-controlled analgesia device. She had a …
4y · Male·perinatal asphyxia
Bradley Piper was born prematurely (34 weeks) at Kilmore Hospital on 22 January 2007 and died from perinatal asphyxia. Expert evidence established that the hypoxic-ischaemic insult occurred before the last hour of labour…
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…
0y · Male·Intrapartum hypoxia due to true knot in umbilical cord with cord wrapped three t…
Tyler Reading-Adams died at 95 minutes old from intrapartum hypoxia caused by a true knot in his umbilical cord wrapped three times around his neck. The mother presented at 40 weeks 6 days gestation with spontaneous rupt…
Male·Extreme prematurity
Ty Lacey was born at 24.2 weeks gestation with Twin to Twin Transfer Syndrome (TTTS) after his co-twin died in utero. His parents explicitly requested full resuscitation and transfer to Sydney. When Mrs Lacey laboured at…
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 …
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…
0y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…
A full-term neonate born after induction of labour died from hypoxic brain injury secondary to meconium aspiration syndrome and chorioamnionitis. The baby presented in poor condition at delivery with thick meconium prese…
0y · Female·Hypoxic episode, probably caused by cord entanglement during delivery
A neonate (Roisin) died within 90 minutes of unattended home birth on 27 March 2009. The mother, Janet Fraser, is an advocate for natural birth and rejected all antenatal care despite risk factors including previous caes…
Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…
Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstru…
1y · Male·Hypoxic ischaemic encephalopathy
Dean Smith, a full-term neonate, was born severely asphyxiated after an induced labour managed at Central Gippsland Health Service. He died from hypoxic-ischaemic encephalopathy within 24 hours. The coroner found critica…
0y · Female·perinatal pneumonia in association with meconium aspiration
Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nin…
0y · Female·Unascertainable
Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …
24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…
A 24-year-old man with schizoaffective disorder and substance abuse killed his 2-year-old son and himself in March 2009. The deceased had been released on licence following a mental impairment finding and was subject to …
0y · 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 preventable failures: escalation of oxytocin augmentati…
0y · Female·Perinatal asphyxia
Poppy Louise Habgood was born at 0100 hours on 10 July 2008 by emergency caesarean section at 42 weeks gestation, weighing 3968g. She was born severely asphyxiated with a heart rate of 60bpm and died at 0126 hours despit…
34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …
A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…
0y · Female·Mechanical asphyxia due to or as a consequence of overlaying while bed-sharing d…
Bela Heidrich, a newborn, died from mechanical asphyxia due to overlaying while bed-sharing with her mother during breastfeeding in hospital. The mother, Zelia, was exhausted after labour and fell asleep while breastfeed…
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