Coronial

329 results for delivery

NSWhospital2011-02-03

Finding&recommendations owens,jonah3648 09

Unknown·Subgaleal Haemorrhage caused by position of forceps on baby's head together with…

…12 December 2008 from a subgaleal haemorrhage. The coroner found the death was directly caused by forceps delivery — specifically the position of the forceps on the baby's head combined with excessive traction and compre…

obstetricsprocedural
VIChome2024-11-21

Finding into death of Baby S

7y · Male·Hypoxic ischaemic encephalopathy in the setting of a breech delivery

…d died at 7 days old. The mother had been counselled by hospital obstetricians about risks of home breech delivery and advised to present to hospital if labour commenced. Despite these clear recommendations and a planned…

obstetricsemergency medicine
SAhospital2023-06-30

Coroner's Finding: Vanin, Levi Shane

29y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…

…prolonged induction and protracted second-stage labour at Lyell McEwin Hospital, followed by instrumental delivery. Initial concerns about delayed delivery and inadequate resuscitation were addressed through expert revie…

obstetricsneonatologydinoprostone
VIChomePodcast2025-02-11

Finding into death of Kathleen Dawn Arnold

30y · Female·Acute ethanol toxicity on a background of chronic alcoholism

…vices but struggled with recurring relapse. Critical to her death was her easy access to alcohol via food delivery platforms, including late-night deliveries when already intoxicated and cognitively compromised. Her moth…

addiction medicinepsychiatrysystemalcohol
SAhome2007-07-12

Coroner's Finding: STEPHEN Esther Ruth

Female·hypoxic-ischaemic encephalopathy due to intrapartum hypoxia due to delayed deliv…

… 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 decelerations were noted. An independent midwife appropr…

obstetricsmidwifery
NThospital2009-05-28

Inquest into the death of Declan McConville

0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery

Declan Brian McConville was born with shoulder dystocia (impacted shoulders) after vacuum-assisted delivery at Royal Darwin Hospital on 31 August 2007. He was stuck in the birth canal for approximately 15 minutes …

obstetricspaediatricsproceduralsystemoxytocin
VIChospital2020-10-19

Finding into death of BABY FF

2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…

…foetal tachycardia and reduced variability on CTG monitoring. After failed attempts at vacuum and forceps delivery in the birthing room, an urgent category-one caesarean section was performed. The infant was born in poor…

obstetricsneonatologymonitoringcommunicationoxytocin
WAhospitalPodcast2017-05-03

Inquest into the Death of Edith Catherine BEE

80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …

…ired use of CO₂ as an imaging agent due to her renal disease. The surgeon used a customised three-way tap delivery system instead of his preferred two-way system because the preferred equipment was unavailable. During th…

vascular surgerygeneral surgeryproceduralsystem
SAhospital2002-09-18

Coroner's Finding: McPHAIL Matthew Anthony

0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…

…ia episodes around 6.55 pm with recovery, followed by total loss of fetal heartbeat between 9.30-9.40 pm. Delivery was by forceps. The child was pale, cyanotic and unresponsive at delivery. Resuscitation was attempted bu…

obstetricsgeneral practicedelayoxytocin
VIChospital2025-05-13

Finding into death of Baby W

0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour

…40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision-making around assi…

obstetricsneonatologydiagnosticproceduralclindamycin
VIChome2016-10-06

Finding into death of Martha Alice Fraser

0y · Female·Intrapartum hypoxia due to breech delivery with head entrapment and associated c…

…tation. Her mother, Ms Wood, went into spontaneous labour at home but did not reach hospital in time. The delivery involved head entrapment and cord compression leading to intrapartum hypoxia and death. The coroner found…

obstetricsneonatologycommunicationdelayadrenaline
VIChospital2025-07-14

Finding into death of Baby Sidney

0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…

…ney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell short of…

obstetricsneonatologydiagnosticcommunicationoxytocin
NSWhospital2016-03-11

Inquest into the death of Elsie COGHILL

0y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…

…r an earlier planned elective caesarean was not completed when the patient presented at 40+ weeks. Vacuum delivery was prolonged but deemed appropriate. Critical gaps included: failure to follow planned antenatal care (e…

obstetricsneonatologycommunicationsystemoxytocin
VICcommunity2025-02-06

Finding into death of Baran Yalcin

29y · Male·Injuries sustained in a motor vehicle collision (bicycle rider)

A 29-year-old Turkish international student and food delivery worker died when his electric bicycle was struck by a van at an intersection in Thornbury, Victoria. He e…

QLDhome2012-06-29

Baby M

2y · Male·Hypoxic-ischaemic encephalopathy

…for approximately 5 minutes before retrieval. Resuscitation commenced at scene around 15-20 minutes after delivery. Despite advanced life support, Baby M suffered irreversible hypoxic-ischaemic encephalopathy from prolon…

neonatologyparamedicinediagnosticdelay
VIChospital2015-12-04

Finding into death of Baby Kylie Hamilton

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 C…

obstetricsmidwiferyproceduraloxytocin
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical cl…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
VIChospital2015-06-12

Finding into death of Baby Chloe Lee Kellett

5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

…erebral hypoxic-ischaemic injury from clinical birth asphyxia, with the insult occurring 6-8 hours before delivery. Clinical concerns: midwives identified multiple CTG decelerations from 11:45 AM onwards but the obstetri…

obstetricspaediatricsdiagnosticcommunicationoxytocin
VICmental health2014-12-19

Finding into death of Melissa Jane Thorn

33y · Female·multiple injuries sustained in a train incident

…ark Private Hospital despite confusion about her legal status. She left the ward opportunistically when a delivery door was left propped open at 7:30am. The coroner found no causal clinical management failures by Dr C. o…

psychiatryemergency medicinesystemcommunicationclozapine
VIChospital2019-09-18

Finding into death of Lucia Grace Sefton (Bowlen)

Female·Head injury in the setting of an obstructed labour

A term-destined baby (35 weeks gestation) died from head injuries sustained during delivery. She presented to hospital with suspected preterm labour, was managed conservatively initially, and progr…

obstetricspaediatricsproceduralsystemcelestone
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