Coronial
QLDhome2012-06-29

Baby M

2y · Male·Hypoxic-ischaemic encephalopathy

…orn at term (35-38 weeks gestation) into a toilet bowl at home on 27 November 2008 after an unrecognised pregnancy. The mother reported no awareness of pregnancy despite a positive pregnancy test earlier in the pregnanc…

neonatologyparamedicinediagnosticdelay
VIChome2025-09-12

Finding into death of Baby H

0y · Female·Unascertained

…spiration, intradural haemorrhage, and placental changes consistent with maternal diabetes and post-term pregnancy (>42 weeks). The cause of death remained unascertained. The coroner found that medical oversight during …

obstetricsneonatologydiagnosticdelay
ACThospitalPodcast2015-12-18

AN INQUEST INTO THE DEATH OF CORRINA ANNE MEDWAY

32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin

…rebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertension on 13 May and treated with labetalol, which was ceased on 16 May despite borderline…

obstetricsgeneral medicinediagnosticmedicationlabetalol
VICcommunity2010-04-12

Finding into death of Veronica Campbell

23y · Female·complications of ruptured ectopic pregnancy with massive intra-abdominal haemorr…

A 23-year-old woman with a ruptured ectopic pregnancy at a rural hospital required urgent transfer to a tertiary centre. The initial response was classified a…

emergency medicineobstetricscommunicationsystemmorphine
VIChome2019-12-11

Finding into death of Maddox Garry Wheeler

0y · Male·Unascertained

…sition, prematurity, and substance exposure. The mother had a known history of cannabis use in her first pregnancy but did not disclose substance use during her second pregnancy despite being directly asked. Clinical le…

neonatologyobstetricscommunicationdelaymethamphetamine
VIChospital2018-10-26

Finding into death of Baby B

1y · Male·Hypoxic-ischaemic encephalopathy and multisystem failure in the setting of extre…

…death was multifactorial. The mother had limited antenatal care despite known methamphetamine use during pregnancy, absent child protection notification, and booking failure by maternity services. The breech presentatio…

obstetricsneonatologydiagnosticsystemmethamphetamine
VIChospital2018-10-05

Finding into death of Baby W

Female·Intrauterine pneumonia and meconium aspiration complicating intrauterine growth …

…ad known substance abuse, prior child protection involvement, and tested positive for amphetamine during pregnancy (October and December 2013), yet did not engage with maternity services until 20 December, just 3 weeks …

obstetricsneonatologydiagnosticsystemmethamphetamine
VIChospital2014-03-21

Finding into death of Michelle Johnson

31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…

…ed the following morning and was found to have a ruptured splenic artery aneurysm, a rare but recognised pregnancy complication. The coroner found her initial assessment was appropriate and no failure to diagnose repres…

obstetricsemergency medicinecommunicationsystempethidine
NSWhospital2019-07-29

Inquest into the death of Naomi Williams

27y · Female·Septicaemia secondary to Neisseria meningitides infection

Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital sign…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
NSWhospital2011-04-01

Clarke,heidimaree1223 09 findings&recommendations

Female·massive intra-abdominal haemorrhage caused by injuries to her right common iliac…

Heidi Maree Clarke, a patient undergoing treatment for ectopic pregnancy, died on 30 April 2009 from massive intra-abdominal haemorrhage caused by injuries to her right common i…

gynaecologyprocedural
WAhome2015-06-08

Inquest into the Death of Baby B

0y · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia

…r healthcare staff. The case highlights the necessity for unambiguous written documentation of high-risk pregnancy decisions and mandatory communication protocols between midwifery programs and medical staff to prevent …

obstetricsmidwiferycommunicationsystem
VIChome2010-11-05

Finding into death of Veronica Therese Campbell

38y · Female·complications following a ruptured ectopic pregnancy

Veronica Campbell, age 38, died on 31 December 2008 from complications of a ruptured ectopic pregnancy. She presented to Cobram District Hospital with severe pain and was diagnosed with a possible ectopic pr…

emergency medicineobstetricscommunicationdelaymorphine
NSWhome2025-09-04

Inquest into the death of Baby MA

0y · Female·Unascertained

… 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's existence. Police later discovered the deceased baby wrapped in cloth behind a bathroom d…

obstetricsemergency medicinedelay
VIChospital2021-11-18

Finding into death of Pippa May Griffiths

0y · Female·Neonatal death in the setting of meconium aspiration

A term neonate died from meconium aspiration three hours after spontaneous labour onset. The mother had presented to hospital the previous day with decreased foetal movements and was discharged without comprehensive asse…

obstetricsmidwiferycommunicationdiagnosticbenzyl penicillin
SAhome2012-06-06

Coroner's Finding: Home Birthing - SPENCER-KOCH Tate and HOBBS Jahli Jean and KAVANAGH Tully Oliver

Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…

…gnancies unsuitable for homebirth: macrosomia with shoulder dystocia risk, breech presentation, and twin pregnancy. Hospital births with continuous monitoring, immediate access to intervention, and availability of skill…

obstetricsmidwiferydiagnosticcommunication
VIChospital2020-03-18

Finding into death of Sommer Bethany Warren

18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…

An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …

obstetricsanaesthesiamedicationdiagnosticropivacaine
NSWhospital2012-12-11

Ty lacey findings dsc guy

Male·Extreme prematurity

Ty Lacey was born at 24.2 weeks gestation with Twin to Twin Transfer Syndrome (TTTS) after his co-twin died in utero. His parents explicitly requested full resuscitation and transfer to Sydney. When Mrs Lacey laboured at…

obstetricsneonatologycommunicationsystem
VIChome2024

Finding into death of Baby E

1y · Female·Neonatal pneumonia, meconium aspiration and chorioamnionitis secondary to prolon…

Baby E died at home one day after birth at 40+ weeks gestation following a prolonged labour in a hired plastic birthing pool. The mother had no antenatal care, no midwifery support, and her Group B Streptococcus status w…

obstetricsneonatologydiagnosticsystem
WAhome2014-12-19

Inquest into the Death of Baby W

9y · Male·Sudden infant death in a boy with bronchitis and otitis media (cause unascertain…

…put to sleep. The coroner identified multiple recognised SUID risk factors including maternal smoking in pregnancy, prone sleeping position, young age, and elevated oxygen requirements from mild respiratory infection. W…

paediatricsforensic medicinecommunicationparacetamol
NThospital2000-04-10

Inquest into the death of Baby J

0y · Female·premature delivery; extreme prematurity

A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foeta…

obstetricsmidwiferycommunicationsystemmisoprostol

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