329 results for “delivery”
Female·Intrauterine pneumonia and meconium aspiration complicating intrauterine growth …
…ber and December 2013), yet did not engage with maternity services until 20 December, just 3 weeks before delivery. Critical failures included: absence of systematic substance use screening during early pregnancy, lack o…
Female·carbon monoxide toxicity
…on monoxide supply; Fernando exploited ease of online ordering, use of business identity, and residential delivery practices. The coroner recommended addition of carbon monoxide to the Poisons Standard and enhanced suppl…
22y · Male·Consistent with drowning
Michael Atakelt, aged 22, died from drowning in the Maribyrnong River on 26 June 2011. He was last seen alive at 7:07pm at Newmarket railway station. His body was found 11 days later near Raleigh Road Bridge. The coroner…
0y · Female·premature delivery; extreme prematurity
… maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a live infant (estimated 21-22 weeks gestation, weighing 515g) was unexpe…
53y · Male·ligature compression of the neck (hanging)
John Stephen Passmore, a 53-year-old man with severe treatment-resistant paranoid schizophrenia, died by suicide while on community leave from psychiatric hospital. He had been an involuntary patient at Graylands Hospita…
0y · Male·Cardiorespiratory failure due to failure of anaesthetic rebreathe bag
…s failure of an anaesthetic rebreathe bag whose rubber had degraded and stuck together, preventing oxygen delivery. The bag should have been identified as defective during cleaning or immediately before use but was not c…
76y · Male·Chest sepsis in a man with ischaemic heart disease
…ularly when family cannot attend ward visits; implement robust final checks between medication labels and delivery bags; improve communication during transitions of care; and recognize that COVID-19 restrictions limiting…
84y · Male·Metastatic oesophageal carcinoma
…tient condition and prognosis. The coroner found no evidence of preventable factors or negligence in care delivery.
0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…
…A. attended when urgently called, caesarean section was delayed approximately 60 minutes from decision to delivery. Clinical lessons include: obstetricians must personally review patients before escalating syntocinon, es…
0y · Male·Perinatal asphyxia
… of membranes at 7:17am. However, this was not escalated to senior staff and labour progressed rapidly to delivery at 7:37am, when the baby was born in severe distress (Apgar 0/0). Autopsy showed severe uteroplacental hy…
0y · Female·Sepsis
… (Staphylococcus aureus) that developed after spontaneous rupture of maternal membranes 48 hours prior to delivery. The infection caused chorioamnionitis with profound foetal inflammatory response, severely compromising …
0y · Male·Perinatal hypoxia
…ed severe global cerebral injury consistent with antenatal hypoxia, with timing of injury 3-5 days before delivery. The mother had multiple presentations during pregnancy with reduced foetal movements, and investigations…
Female·meconium aspiration
… Meconium of tan colour was present, indicating the baby had inhaled meconium at least 24-48 hours before delivery. The coroner found the medical team's response time was acceptable, all procedures were competently perfo…
0y · Male·neonatal encephalopathy due to perinatal compromise
Jaxon McGrorey-Smith, a full-term neonate, was delivered by caesarean section after prolonged labour. He developed seizures and signs of hypoxic-ischaemic encephalopathy (HIE) within hours of birth, with MRI imaging conf…
55y · Male·Multiple gunshot injury to the chest
…e remains unsolved. This case does not involve medical error, clinical management failures, or healthcare delivery issues—it is a criminal homicide investigation. No clinical lessons or preventability factors are applica…
34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …
…4-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 agents, …
Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…
…ding carer involvement. Key system issues were staff stress, resource constraints, and fragmented service delivery. The coroner found clinical judgements were amenable to review and several fell below acceptable standard…
0y · Female·Intra-uterine hypoxia
…s death resulted from intra-uterine hypoxia, likely multifactorial including severe head impaction during delivery, which was unforeseeable and extremely difficult to manage despite appropriate clinical manoeuvres.
30y · Male·Sudden unexpected death in epilepsy
…btherapeutic anticonvulsant levels, and the importance of culturally appropriate engagement in healthcare delivery to First Nations patients.
0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…
…rom 2100 hours but medical staff were not escalated to review until after 0138 hours when vacuum-assisted delivery was attempted. Lucy was born in poor condition with severe metabolic acidosis and required emergency retr…
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