189 results
0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…
George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…
0y · Female·Sepsis
Baby Lily Irwin died of sepsis caused by ascending bacterial infection (Staphylococcus aureus) that developed after spontaneous rupture of maternal membranes 48 hours prior to delivery. The infection caused chorioamnioni…
0y · Female·Intra-uterine hypoxia
Baby Paula O'Shea was born at Sandringham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detecti…
4y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…
Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner foun…
2y · Male·Severe hypoxic ischaemic encephalopathy (grade 3)
A term two-day-old baby died of severe hypoxic-ischaemic encephalopathy (grade 3) following a home birth on a farm 25km from hospital. The birth was complicated by shoulder dystocia and profound asphyxia. Although expert…
31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…
Michelle Johnson, a 31-year-old pregnant woman at 32 weeks gestation, presented to the Royal Women's Hospital with sudden-onset severe left-sided abdominal pain and hypotension on 21 March 2010. She was assessed by regis…
0y · Male·complications of intrauterine hypoxia
Baby Jacob Hill died from intrauterine hypoxia following an obstructed labour managed at Sunshine Hospital. A 39-week primiparous labour was complicated by deep transverse arrest. After initial assessment suggesting caes…
41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndr…
Kerri Gunn, a 41-year-old woman five days post-caesarean delivery, presented to emergency with frontal headache, elevated blood pressure, proteinuria, abnormal liver function and lower limb oedema. She was admitted under…
0y · Female·Pulmonary hypoplasia in the setting of ascending maternal genital tract infectio…
Hannah McNeil, a term neonate, died from pulmonary hypoplasia secondary to ascending maternal genital tract infection. She was born via emergency caesarean section after induction of labour for brow presentation. Despite…
21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…
Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…
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·acute blood loss due to velamentous insertion of the umbilical cord with likely …
A neonate died from acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa, a rare condition causing vulnerability to catastrophic bleeding. Key clinical lessons include: (1) prenatal…
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