189 results
20y · Female·unascertained
Alyce Pollett, a 20-year-old pregnant woman, was found dead in her bed on 14 July 2011 after being unwell for approximately one week with flu-like symptoms. Autopsy findings were concerning for possible asphyxia due to n…
0y · Male·Amniotic fluid aspiration (severe); with contribution from thin umbilical cord a…
Archer Langley died at age 1 hour from severe amniotic fluid aspiration following delivery by emergency caesarean section for obstructed labour. His mother's labour was prolonged and difficult, but critical delays occurr…
0y · Male·Head injuries (birth trauma) secondary to obstructed labour and fetal macrosomia…
Nixon Martin Tonkin died from head injuries sustained during caesarean delivery for obstructed labour at 38 weeks gestation. The infant's head became deeply impacted in the maternal pelvis after prolonged second-stage la…
Female·neck and chest injuries from motor vehicle crash
Sarah Jane Paino, 33 weeks pregnant, died from massive neck and chest injuries sustained in a motor vehicle crash in Hobart on 22 January 2016. An unlicensed 15-year-old driver operating a stolen vehicle at twice the spe…
0y · Female·Group B Streptococcus meningitis and sepsis
An 18-day-old baby died from late-onset Group B Streptococcus (GBS) meningitis and sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm)…
0y · Female·Sudden Infant Death Syndrome (SIDS Category I)
Livinia Rose Kenna, a 19-day-old infant, died from Sudden Infant Death Syndrome (SIDS Category I) on 16 April 2016. She was placed to sleep in a bassinet with multiple unsafe sleeping practices: prone positioning, multip…
0y · Male·extreme prematurity associated with acute chorioamnionitis
A 23-week gestation infant (DF) was born at home in Tasmania and transferred by ambulance to Royal Hobart Hospital with signs of life (sinus bradycardia at 26 bpm). Despite CPR and emergency treatment, the infant died on…
0y · Female·Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficien…
Emma, born 26 July 2011, developed severe hypoxic-ischaemic encephalopathy associated with chronic placental insufficiency and died at 4 days old. Her mother reported reduced foetal movements after 34 weeks' gestation, b…
0y · Female·Perinatal asphyxia
Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…
46y · Female·acute mixed drug toxicity due to accidental self-administered drug overdose
Dr V., an obstetrician-gynaecologist trainee, died from acute mixed drug toxicity on 18 January 2013 following self-administration of multiple anaesthetic drugs (propofol, midazolam, fentanyl, alfentanil) via intravenous…
0y · Female·Intrapartum hypoxia due to breech delivery with head entrapment and associated c…
Martha Alice Fraser was born on 30 May 2011 following an unplanned home birth in a frank breech presentation. Her mother, Ms Wood, went into spontaneous labour at home but did not reach hospital in time. The delivery inv…
0y · Male·unascertained
Baby Z, born to a serving prisoner on 3 March 2011, died suddenly on 3 April 2011 at Bandyup Women's Prison at one month of age. Despite extensive forensic investigation, the cause of death remained unascertained, though…
0y · Male·Hypoxic ischaemic encephalopathy (brain damage) sustained during and just after …
A newborn died from hypoxic-ischaemic encephalopathy following a home birth without medical assistance. The mother had significant risk factors: hepatitis C, anaemia, and transverse fetal lie confirmed at 38+ weeks gesta…
0y · Female·Persistent pulmonary hypertension in the newborn (PPHN)
Summer Jamsek was born at 4pm on 4 April 2010 with persistent pulmonary hypertension of the newborn (PPHN) and died 5 April 2010 at Royal Children's Hospital. The coroner found Baby Summer died from PPHN but was not sati…
42y · Female·Global cerebral ischaemia in a setting of anaesthesia
A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning puls…
25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss
A 25-year-old pregnant woman (23 weeks) presented to hospital with sudden left upper quadrant abdominal pain and loss of consciousness. Clinical assessment identified renal colic and gallstones as likely diagnoses. She r…
0y · Male·Perinatal asphyxia
Noah Cheron-Duncan, a full-term neonate born at Sandringham Hospital on 19 November 2014, died from perinatal asphyxia. Labour was uncomplicated and FHR monitoring appeared reassuring, but no foetal heart rate was detect…
36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…
Caroline Lovell, 36, died from postpartum haemorrhage following home birth of her second child. She had significant risk factors: prior PPH with first child and uterine fibroid, but these were not properly investigated b…
0y · Female·head injuries
Twin infant died of head injuries inflicted by her mother, a previously well-functioning woman suffering unrecognized postnatal depression during the stressful period of managing unsettled twins with colic and poor weigh…
0y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…
Elsie Coghill, a newborn, died from hypoxic ischaemic encephalopathy due to multiple factors including an underlying lung abnormality from antenatal distress, an undetected apnoeic episode during transfer, and undiagnose…
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