0y · Male·extreme prematurity associated with acute chorioamnionitis
…m). Despite CPR and emergency treatment, the infant died on the day of birth. Autopsy confirmed extreme prematurity with acute chorioamnionitis as the cause. The coroner found that treatment by both paramedics and hospi…
0y · Female·OEIS Complex (Omphalocoele, Exstrophy of Cloaca, Imperforate Anus, Spinal Defect…
…dition involving omphalocoele, exstrophy of cloaca, imperforate anus, and spinal defects) combined with prematurity at 32 weeks gestation. The defect was incompatible with life—the large abdominal wall defect caused let…
0y · Unknown·Unascertained
…ts on an adult bed with soft pillows and loose bedding. Baby A had multiple SIDS risk factors including prematurity, low birthweight, co-sleeping arrangements, soft bedding, and prenatal and postnatal smoke exposure. Po…
0y · Female·Pneumonia in an infant with surgically repaired congenital heart disease, premat…
A 9.5-month-old girl with complex medical history (prematurity at 29 weeks, congenital heart disease status post multiple repairs, necrotising enterocolitis with ileo…
0y · Female·Suffocation due to unsafe sleeping environment with overlying and/or bedding ent…
…rs included maternal smoking despite safe sleep education at health assessments, poor home hygiene, and prematurity. The parents were aware of safe sleep guidelines but failed to implement them. Key lessons: reinforce s…
0y · Male·Unascertained
…ould not be determined but multiple factors may have contributed including unsafe co-sleeping position, prematurity, and substance exposure. The mother had a known history of cannabis use in her first pregnancy but did …
0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…
…terioration preceded the morphine administration. Jordan's death resulted from complications of extreme prematurity combined with being born outside a tertiary centre without adequate antenatal steroids. Clinical lesson…
0y · Male·Sudden Infant Death Syndrome (SIDS) against a background of sub-glottic stenosis…
…ined to be Sudden Infant Death Syndrome (SIDS) against a background of sub-glottic stenosis and extreme prematurity; the mechanism remains unknown. Key clinical lessons include: sub-glottic stenosis is a recognized comp…
0y · Unknown·Mechanical asphyxiation as a consequence of overlaying
…rning shift midwife did not intervene, leaving Baby A co-sleeping despite known high-risk SUDI factors (prematurity, low birth weight, maternal fatigue). Key clinical lessons include: consistently applying safe sleeping…
5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained
…y related to unsafe sleep position on soft objects combined with identified SUDI risk factors including prematurity, low birth weight, and paternal smoking. Key clinical lessons include the importance of accurate medica…
8y · Male·prematurity-associated lung and bowel disease
…luding chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associated lung and bowel disease while in parental care. Critical clinical lessons include: (1) his we…
0y · Female·Sudden infant death while bed-sharing
A 7-week-old premature infant died of sudden infant death while bed-sharing with her mother on a couch. The infant was born at 33 weeks gestation weighing 1.7kg and discharged home after achieving adequate growth. She wa…
0y · Female·Unascertainable
…esponsive after co-sleeping with her father in a warm bedroom. Multiple SIDS risk factors were present: prematurity, co-sleeping, parental smoking and substance use history, and hyperthermia. The coroner identified crit…
0y · Female·premature delivery; extreme prematurity
…midwife placed the infant in warm bedding and monitored it. The baby died 80 minutes later from extreme prematurity. The coroner found the doctor failed to recognise his duty of care to the born infant, leading to a 're…
0y · Female·sudden death in an infant with broncho-pulmonary dysplasia
A 74-day-old premature infant (27 weeks gestation) died unexpectedly at home three days after discharge from hospital. Post-mortem examination revealed broncho-pulmonary dysplasia (BPD), which was clinically silent and u…
0y · Male·Unascertained
A 5-month-old boy, born prematurely, died suddenly and unexpectedly at home on 30 August 2011 while placed in a baby hammock. Despite extensive autopsy investigation, the cause of death remained unascertained; possible e…
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
One-month-old Liam Woodcock, born extremely prematurely at 27.5 weeks gestation weighing approximately 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congeni…
4y · Male·perinatal asphyxia
Bradley Piper was born prematurely (34 weeks) at Kilmore Hospital on 22 January 2007 and died from perinatal asphyxia. Expert evidence established that the hypoxic-ischaemic insult occurred before the last hour of labour…
0y · Male·Unascertained in the setting of a remote head injury
…perpetrator accountable. Child Protection did not use the child's prolonged hospitalisation (27.5 weeks prematurity) to assess parenting capacity or develop safety plans. Services over-relied on the young mother (CFT, a…
1y · Female·acute on chronic respiratory failure
Kara Compton, aged 22 months with Down's syndrome and chronic respiratory disease requiring home oxygen, died from acute on chronic respiratory failure following a dog bite attack. Injuries caused blood loss which, combi…
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