0y · Female·Intra-uterine hypoxia
…ham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detection of uterine contractions. From appro…
0y · Female·Intrapartum asphyxia refractory to postpartum resuscitation due to amniotic flui…
A term neonate died one hour after emergency caesarean section for fetal distress, caused by intrapartum asphyxia due to meconium aspiration. While labour induction, oxytocin dosing, and emergency surgery were appropriat…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
…hen labour did not progress normally, the mother was transferred to a monitoring suite for continuous cardiotocography (CTG). Critically, the CTG recorded the mother's heart rate instead of the baby's for approximately 2…
0y · Female·Perinatal asphyxia
Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…
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·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…
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 …
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…
Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…
Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstru…
0y · Male·Perinatal hypoxia
An 8-day-old neonate died of perinatal hypoxia on 14 December 2019, 8 days after emergency caesarean section. The infant presented with seizures, hypotonia, and severe encephalopathy. Autopsy revealed severe global cereb…
0y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia
A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…
1y · Female·Neonatal pneumonia, meconium aspiration and chorioamnionitis secondary to prolon…
…d with plastic materials). The coroner found the death preventable: hospital birth would have enabled cardiotocography to detect foetal distress, prompt intervention, GBS screening with antibiotics, and immediate neonata…
Female·meconium aspiration
Talisha Hildebrandt was stillborn at Ayr Hospital on 7 January 2007 due to meconium aspiration. The pregnancy was low-risk and managed appropriately. A CTG monitor showed concerning fetal heart rate changes, prompting ur…
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
… meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission cardiotocography (CTG) monitoring was inadequate (less than 5 minutes, policy required 10+ minutes). During labour, fo…
0y · Female·Perinatal asphyxia
Summer Elizabeth Rose Niehoff died from perinatal asphyxia hours after vaginal birth following a prolonged labour in hospital. The coroner found multiple clinically preventable failures: escalation of oxytocin augmentati…
0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…
…regnancy complicated by spontaneous rupture of membranes and underwent labor induction. During labor, cardiotocography traces deteriorated from 2100 hours but medical staff were not escalated to review until after 0138 h…
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 · 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…
6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia
HC was a neonate who died at 6 days old from global cerebral ischaemia secondary to perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons …
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