Baby M

0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fall, due to Group B Streptococcus infection (sepsis)

Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nurse fell while carrying the newborn to another resuscitation table after the primary table lacked a compatible connector for ventilation equipment. Key clinical lessons include: inadequate prenatal care with missed opportunities for earlier induction (pregnancy went 14 days post-due date); failure to admit the mother to hospital when she called with strong contractions and GBS-positive status; lack of daily equipment checking (resuscitation table non-functional); failure to administer prescribed antibiotics; and no use of available Ambu bag during critical first 4 minutes. While early antibiotic administration likely would not have altered outcome given the severe head injury, better prenatal management and equipment maintenance could have prevented the precipitous delivery and fall.