148 results
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…
0y · Male·cardiogenic shock and neonatal encephalopathy
Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…
0y · Male·Sequelae of drug toxicity (poisoning) — specifically respiratory depression and …
Michael Anderson was a 9-day-old Aboriginal infant who collapsed at King Edward Memorial Hospital on 15 November 2000 after being administered a gross overdose of paracetamol and codeine (likely via crushed panadeine for…
0y · Female·sudden death in an infant with broncho-pulmonary dysplasia
A 74-day-old premature infant (27 weeks gestation) died unexpectedly at home three days after discharge from hospital. Post-mortem examination revealed broncho-pulmonary dysplasia (BPD), which was clinically silent and u…
0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…
A full-term infant, Matthew Anthony McPhail, was delivered at 9.55 pm on 9 July 2000 at Naracoorte Health Service with no signs of life (Apgar 0). CTG monitoring during labour showed concerning fetal bradycardia episodes…
0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia
Jayden Tyler Trimboli, aged 6 days, died from hypoxic-ischaemic encephalopathy caused by a prolonged fetal bradycardia episode between 11:10pm and 11:50pm on 18 September 1998. The critical failure was that the cardiotoc…
0y · Female·premature delivery; extreme prematurity
A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…
0y · Female·Subdural and subarachnoid haemorrhages due to late onset vitamin K deficiency bl…
A 33-day-old exclusively breastfed baby died from subdural and subarachnoid haemorrhages caused by late-onset vitamin K deficiency bleeding (VKDB). The parents, exercising informed choice based on spiritual beliefs, decl…
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