Coroner's Finding: HUTCHINSON Matthew

0y · Male·cardiogenic shock and neonatal encephalopathy

Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical failures included: failure to insert an arterial line early (only placed 12 hours after birth), inadequate blood pressure monitoring before and during hypothermic neuroprotection therapy, failure to assess baseline cardiovascular and metabolic status before commencing cooling therapy, delayed treatment of metabolic acidosis, and incomplete coagulation assessment. These monitoring gaps prevented clinicians from recognizing progressive hypotension and acidosis. The case highlights the need for comprehensive cardiovascular and biochemical monitoring in sick neonates, particularly before experimental therapies. No autopsy was performed, leaving alternative diagnoses (birth trauma, infection, metabolic disorders, congenital heart disease) unexcluded.