0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
… to uterine hyperstimulation by ceasing syntocinon; failure to escalate multiple abnormal CTG findings (bradycardia, tachysystole, decelerations) to the consultant obstetrician throughout labour; and absence of the cons…
0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…
…iculate risks, supported home birth plans despite clinical concerns, and delayed transfer to hospital when foetal bradycardia developed during labour. The bradycardia persisted for over 40 minutes before hospital transfe…
0y · Male·hypoxic ischaemic encephalopathy
…. After artificial rupture of membranes during labour induction, the foetus developed severe, sustained bradycardia lasting approximately 30 minutes before delivery. The emergency caesarean section decision was made at …
0y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
…rd. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart rate monitoring showed intermittent decelerations and bradycardia from 0300 hours onwards. The locum…
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…
0y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia
…essed slowly; cervical dilation remained at 8cm for 2.5 hours despite mild-moderate contractions. Fetal bradycardia developed at 7:30pm and emergency caesarean section was performed 22 minutes later. The baby was born s…
0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…
…te Health Service with no signs of life (Apgar 0). CTG monitoring during labour showed concerning fetal bradycardia episodes around 6.55 pm with recovery, followed by total loss of fetal heartbeat between 9.30-9.40 pm. …
0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia
…den 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 cardiotocog…
0y · Female·Perinatal asphyxia
… consultant obstetrician despite clear clinical deterioration, (3) false reassurance from an unusually low foetal scalp lactate result (1.3 mmol/L) clinically inconsistent with CTG findings, and (4) lack of clear communi…
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…
0y · Female·Intrapartum asphyxia refractory to postpartum resuscitation due to amniotic flui…
…n weaknesses may not have altered the outcome, the coroner found them concerning and recommended mandatory Foetal Surveillance Education Program certification for all medical staff, recertified every two years, and imple…
0y · Female·Perinatal asphyxia
… asphyxia. Autopsy findings suggested cord compression occurring 4-6 hours before delivery had compromised foetal wellbeing, though no compromise was detected during labour or antenatally. The neonatal resuscitation enco…
0y · Female·Peripartum hypoxia
Mia Davies died from peripartum hypoxia after a prolonged and poorly managed labour at Royal Brisbane and Women's Hospital. She had been diagnosed with multiple congenital anomalies (atrioventricular septal defect, oesop…
0y · Male·Complications following forceps delivery
… include: (1) complex forceps deliveries with red flags (malposition, failed initial application, fetal bradycardia) should be escalated to operating theatre with consultant supervision rather than attempted in birthing…
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 …
0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…
Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She…
4y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…
Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner foun…
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