Finding into death of Sebastian Hewitt

2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure

Sebastian Hewitt, born at 36 weeks gestation following maternal ante-partum haemorrhage and abnormal CTG traces, died from perinatal asphyxia leading to cerebral anoxia and multi-organ failure at 3 days old. Critical clinical lessons emerged regarding neonatal assessment: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat blood gas analysis within 30-60 minutes of delivery. Significant hypoglycaemia (BSL 1.3-1.7 mmol/L) in the first hours of life should prompt immediate intravenous dextrose rather than continued oral feeding. Dr M.'s conservative approach, whilst appropriate for stable infants, was inadequate for this at-risk baby born after acute blood loss. Systems failures in pathology result communication (2.5-hour delays) delayed necessary escalation and NETS transfer. The case demonstrates importance of integrating clinical signs, objective investigations, and appropriate clinical deterioration responses rather than optimistic reassessment despite objective warning signs.