12 results for “low birth weight”
0y · Male·positional asphyxia
… Boba Wrap fabric sling in an incorrect position on 8 April 2019. The sling was positioned horizontally and low across his mother's abdomen, contrary to manufacturer instructions requiring vertical positioning on the ch…
5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained
A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemi…
Female·Sepsis in the setting of a lotus birth
… emergency caesarean section developed sepsis and died at 2 days of age. She had been delivered with lotus birth (cord left attached to placenta) and vaginal seeding (maternal vaginal fluid applied to baby) despite obst…
0y · Unknown·Mechanical asphyxiation as a consequence of overlaying
…hile co-sleeping with his mother at Derby Hospital. The baby had been transferred from Darwin Hospital for weight monitoring and was seen co-sleeping multiple times by midwives. While the night shift midwife removed him …
3y · Male·Escherichia Coli sepsis in a low birth weight infant
…ring after initial assessment, no pre-discharge paediatric examination, and discharge without paediatric follow-up documentation. The independent expert found that whilst the decision for ward care was initially reasona…
Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…
…other children), failure to provide safe sleeping education despite policy requirements, and decisions to allow discharge without protective orders. CHaPS and hospitals provided adequate safe sleeping information, but C…
0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease
…to take the baby home with minimal monitoring instructions. The baby deteriorated overnight and died the following morning. The Coroner found that immediate medical contact, appropriate medications, and hospital transfe…
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
…ion weighing approximately 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congenital heart disease (pulmonary atresia with intact ventricular septum and rig…
Female·Multiple: undetermined consistent with overlaying (Naomi Kade); undetermined pos…
This inquest examined five infant deaths (aged 1 month to 10 months) occurring between July 2007 and November 2008, all involving co-sleeping with adults. Deaths were attributed to undetermined causes, possible overlayin…
0y · Female·perinatal pneumonia in association with meconium aspiration
…l. Observations were taken only once, revealing elevated temperature (38°C) and heart rate (172), but no follow-up observations were conducted and no treatment was initiated. Nursing staff failed to monitor vital signs …
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
…e (Buvidal) injection without prior stabilisation on sublingual Suboxone. She was opioid-naïve or with very low tolerance, obese (BMI 54), had poorly controlled diabetes, and was prescribed quetiapine. Following injecti…
3y · Male·unascertained
…and cannabis use. Despite referral to SAFE START and child protection involvement, care coordination and follow-up were suboptimal. The coroner identified gaps in formal safety and risk assessment review after hospital …
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