Coronial

11 results for umbilical catheter insertion

VIChospital2021-11-08

Finding into death of Baby MNL

<1y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia

…1/5/10/20 minutes) with profound acidosis indicating prolonged hypoxia. Post-mortem revealed hypercoiled umbilical cord with suspected vascular obstruction and thrombus. Key learning: proper partograph documentation is …

obstetricsneonatologysystemcommunicationterbutaline
VIChospital2025-09-29

Finding into death of Baby M

<1y · Female·Perinatal asphyxia

…could have been considered earlier; laryngeal mask airway should be considered after failed intubations; umbilical catheter securement technique requires careful attention to prevent blockage. However, expert review con…

obstetricsneonatologyproceduralcommunicationadrenaline
VIChospital2011-07-11

Finding into death of Cara Grace Zambelli

<1y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord

A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second st…

obstetricsneonatologycommunicationsystemadrenaline
QLDhospital2026-07-24

Inquest into the death of Wren Marion Preo

<1y · Female·Hypoxic ischaemic encephalopathy caused by respiratory failure following severe …

Baby Wren Marion Preo, born at term after precipitate labour at Atherton Hospital in Queensland, died at approximately 8 hours of age from hypoxic ischaemic encephalopathy secondary to severe meconium aspiration that occ…

midwiferyneonatologybenzylpenicillin
VIChospital2018-10-05

Finding into death of Baby W

Female·Intrauterine pneumonia and meconium aspiration complicating intrauterine growth …

Baby W was born at 37+5 weeks in an ambulance and died at Bendigo Hospital from intrauterine pneumonia and meconium aspiration secondary to intrauterine growth restriction related to maternal amphetamine use. The mother …

obstetricsneonatologydiagnosticsystemmethamphetamine
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

…), failure to check coagulation status until 7:45 pm despite therapeutic anticoagulation, lack of urinary catheter insertion until 8:00 pm, delayed antibiotic administration, and poor inter-team communication and documen…

general surgeryintensive carediagnosticdelaywarfarin
VIChospital2015-06-12

Finding into death of Baby Chloe Lee Kellett

<1y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…

obstetricspaediatricsdiagnosticcommunicationoxytocin
VIChospital2025-01-29

Finding into death of Amir Mohammad Iran

<1y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax

A 2-day-old term infant (2670g, small-for-gestational-age) presented with respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensatio…

neonatologyobstetricsdiagnosticdelaysurfactant
VIChospital2020-10-19

Finding into death of BABY FF

<1y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…

A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 w…

obstetricsneonatologymonitoringcommunicationoxytocin
VIChospital2020-07-02

Finding into death of Cai Wheeler-Trow

<1y · Male·Head injury in the setting of labour

Baby Cai Wheeler-Trow was born at 36 weeks and 2 days following a failed instrumental delivery and emergency caesarean section. He developed a skull fracture and subgaleal haemorrhage, presenting with clinical deteriorat…

obstetricspaediatricsdiagnosticcommunication
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

<1y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…

Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She…

obstetricsneonatologycommunicationsystemmagnesium sulphate

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