Finding into death of Hannah McNeil

0y · Female·Pulmonary hypoplasia in the setting of ascending maternal genital tract infection

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 resuscitation efforts, she remained bradycardic and died 22 minutes after birth. The coroner found pulmonary hypoplasia, an undiagnosable prenatatal condition with low survival, was the primary cause. While concerns were raised about labour management timing, CTG interpretation, and delayed Code Blue activation (5 minutes), the coroner determined these were unlikely to have altered outcome given the severe underlying lung pathology. The hospital conducted a Root Cause Analysis and implemented improvements to neonatal resuscitation guidelines and education.