22 results for “epidural insertion”
72y · Female·Intrathecal toxicity of bupivacaine and morphine
…0, a senior palliative care physician ordered a bolus dose of 5mg morphine and 3ml bupivacaine, intending epidural administration but the line was intrathecal. These doses were excessive for intrathecal delivery. The pat…
0y · Male·hypoxic ischaemic encephalopathy
…as not adequately informed of the clinical urgency. A spinal anaesthetic was attempted unsuccessfully; an epidural was chosen instead, further delaying delivery. Had the consultant been briefed appropriately or requested…
18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…
…hypertensive medication or magnesium sulphate. Instead, the treating anaesthetist administered additional epidural analgesia, expecting this to lower blood pressure. At 1810 hours she became drowsy with eyelid flickering…
0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…
George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…
0y · Male·complications of intrauterine hypoxia
Baby Jacob Hill died from intrauterine hypoxia following an obstructed labour managed at Sunshine Hospital. A 39-week primiparous labour was complicated by deep transverse arrest. After initial assessment suggesting caes…
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 before …
0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a …
A neonate died shortly after birth from hypoxia due to intrauterine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother at…
0y · Female·Pulmonary hypoplasia in the setting of ascending maternal genital tract infectio…
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…
5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…
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…
2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…
A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 w…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
5y · Male·complications of blunt force injury to the head
A 5-year-old boy died from complications of blunt force head injury sustained on 19-20 March 2010. He presented to a rural hospital unresponsive, with the initial account not mentioning head trauma. The attending doctor …
31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…
Laura Marguerite Sinclair, 31-year-old primigravida, died from post-partum haemorrhage associated with amniotic fluid embolism (AFE) and uterine hypotonia. She underwent emergency caesarean section for foetal distress at…
28y · Male·MRSA sepsis
Mahmoud Allam, a 28-year-old man, died from MRSA sepsis whilst in custody at Parklea Correctional Centre. He initially presented with upper respiratory symptoms on 11 June 2016, followed by increasing symptoms including …
0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…
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 progressed to spontaneous la…
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 …
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…
0y · Male·Amniotic fluid aspiration (severe); with contribution from thin umbilical cord a…
Archer Langley died at age 1 hour from severe amniotic fluid aspiration following delivery by emergency caesarean section for obstructed labour. His mother's labour was prolonged and difficult, but critical delays occurr…
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