107 results
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…
Owen Appleby, born at Portland Hospital after labour induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APG…
3y · Male·unascertainable; malnourishment was a significant contributing factor
Bradley Frederick Whitehouse, aged 3 months, died on 10 February 2008 from causes ruled unascertainable. He was severely malnourished and emaciated at death, having deteriorated dramatically over the final month of life.…
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …
Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…
Helani Sirianni, born 8 February 2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extract…
Jessica: disseminated intravascular coagulation following haemorrhage (subgaleal…
Two neonates died from complications of subgaleal haemorrhage following ventouse extraction. Jessica Stemmer (7 hours old) died from disseminated intravascular coagulation after subgaleal haemorrhage. Thomas Mahar (8 day…
38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)
Susannah McLevie, a 38-year-old woman, died on 6 April 2006 from untreated Group A Streptococcal septicaemia (puerperal sepsis) following childbirth at Osborne Park Hospital. She developed fever (38°C) at 3am on 5 April,…
8y · Male·Hypoxic Ischaemic Encephalopathy resulting from asphyxiation due to co-sleeping …
Nathaniel West, an 8-day-old Aboriginal newborn, died from hypoxic ischaemic encephalopathy following accidental asphyxiation due to co-sleeping (bed-sharing) with his mother at Kalgoorlie Regional Hospital on 4 May 2006…
Female·meconium aspiration
Talisha Hildebrandt was stillborn at Ayr Hospital on 7 January 2007 due to meconium aspiration. The pregnancy was low-risk and managed appropriately. A CTG monitor showed concerning fetal heart rate changes, prompting ur…
0y · Female·Group B Streptococcus infection
A 7-hour-old neonate died from early-onset Group B Streptococcus (GBS) infection contracted during labour. The mother's GBS screening test at 35-37 weeks gestation was reported negative, and no antibiotic prophylaxis was…
29y · Female·Multisystem organ failure following postpartum haemorrhage due to atonic uterus
Rebecca Murray, 29, died from multisystem organ failure following postpartum haemorrhage after an emergency caesarean section at Bathurst Base Hospital on 24–25 June 2007. The coroner found her death preventable. Key cli…
0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery
Declan Brian McConville was born with shoulder dystocia (impacted shoulders) after vacuum-assisted delivery at Royal Darwin Hospital on 31 August 2007. He was stuck in the birth canal for approximately 15 minutes before …
0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…
Georgia Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contribut…
0y · Male·Intrapartum head injuries secondary to brow presentation and obstructed labour
Benjamin Glasgow died shortly after emergency caesarean delivery at 12:30 pm on 19 October 2006 for brow presentation, an obstructed labour. Autopsy revealed unprecedented multiple skull fractures and severe brain injury…
Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…
William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation …
0y · Male·hypoxic ischaemic encephalopathy
Riley Krol, a 11-day-old male infant, died from hypoxic ischaemic encephalopathy following emergency caesarean section delivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus d…
0y · Female·undetermined; possible suffocation not definitively established at autopsy
A 4-week-old neonate died at home with undetermined cause, though suffocation on a soft pillow was considered possible. The infant was born prematurely on a concrete pavement to a mother with untreated opioid addiction a…
1y · Female·sudden unexpected death in infancy due to hypoxic episode while co-bedding with …
Arisa Huber, a newborn, died from sudden unexpected death in infancy (SUDI) due to hypoxic episode while co-bedding with her exhausted mother in a postnatal ward. The infant was found without breathing or pulse at 6:45am…
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…
31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…
Laura Marguerite Sinclair, 31-year-old primigravida, died from post-partum haemorrhage associated with amniotic fluid embolism (AFE) and uterine hypotonia. She underwent emergency caesarean section for foetal distress at…
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