189 results
0y · Female·Perinatal asphyxia
A 10-day-old infant died from perinatal asphyxia after being born in a home birthing pool. The mother entered the pool without a midwife present after spontaneous rupture of membranes during precipitous labour. Critical …
0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…
Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She…
35y · Female·Stab wound to chest penetrating the descending thoracic aorta resulting in catas…
DM, a 35-year-old woman, died from a stab wound to the chest inflicted by her husband during a domestic violence incident on 26 June 2011. The wound penetrated the descending thoracic aorta, causing catastrophic blood lo…
0y · Female·Blunt head trauma from multiple deliberate blows inflicted by father
Ebony Napier, aged 4 months, died from blunt head trauma resulting from multiple deliberate blows inflicted by her father Bradley Napier-Tucker over several weeks. A critical failure occurred when the South Australian ch…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
0y · Female·perinatal asphyxia
Baby Kylie Hamilton, a 3-day-old neonate, died from perinatal asphyxia following emergency Caesarean delivery during her mother's induced labour. The mother had gestational diabetes and the fetus showed concerning CTG ab…
36y · Female·Haemorrhage complicating elective caesarean section (placenta praevia accreta)
Ms. Thi Lu, aged 36, died from massive hemorrhage following caesarean section for placenta praevia with underlying placenta accreta. Although imaging could not definitively exclude accreta preoperatively, high-risk prepa…
35y · Female·Acute right heart failure (cor pulmonale) following intravenous injection of cru…
A 35-year-old woman with chronic hepatitis C and long-standing intravenous drug use died from acute right heart failure (cor pulmonale) following injection of crushed Xanax tablets. She presented to hospital with cardiog…
0y · Female·Global hypoxic-ischaemic injury of unknown cause
A three-day-old girl, Baby Kirat, died from global hypoxic-ischaemic brain injury sustained during co-sleeping with her mother in a hospital maternity ward on 9 July 2013. She was resuscitated and transferred to NICU but…
0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…
5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…
0y · Male·intrapartum hypoxia due to placental abruption
A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home birth, disengaged from hospital when her preferences for birth management (va…
0y · Male·Group B Streptococcal infection and meconium aspiration with early bronchopneumo…
A newborn died of Group B Streptococcal (GBS) infection and meconium aspiration bronchopneumonia less than three hours after planned home birth. The infant was born to a woman with prior traumatic hospital birth who had …
0y · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia
Baby B suffered severe perinatal asphyxia during a planned home birth and died from hypoxic ischaemic encephalopathy. An obstetrician recommended hospital delivery based on the mother's previous unexplained neonatal emer…
39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…
Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally…
0y · Female·meconium aspiration
A full-term female infant (41 weeks 3 days) died from meconium aspiration during a planned home water birth attended by an experienced midwife. The mother had gestational diabetes and a history of macrosomic babies—risk …
1y · Female·cystic encephalomalacia
Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% ri…
Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome
A full-term baby born at 39 weeks died from hypoxic-ischaemic encephalopathy due to meconium aspiration. Critical failures in fetal monitoring were identified: the admission CTG was abnormal but not recognised as such by…
5y · Female·Sudden Infant Death Syndrome Category II
A 5-month-old infant died from Sudden Infant Death Syndrome (SIDS II) after being placed prone to sleep in a portable cot with additional bedding including thick blankets, a foam couch mattress, and rolled blankets to fi…
3y · Male·Escherichia Coli sepsis in a low birth weight infant
Noah Sheekey, a small-for-gestational-age neonate, died of E. coli sepsis at 3 days old, one day after discharge from hospital. Although his initial condition was reassuring, he was managed on the postnatal ward rather t…
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