Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…
…2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extraction procedure itself was appropri…
0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…
…IE) from prolonged asphyxia during difficult delivery, and massive subgaleal haemorrhage from unsuccessful vacuum extraction. Clinical failures included: inadequate determination of fetal position (no ultrasound used des…
0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery
Declan Brian McConville was born with shoulder dystocia (impacted shoulders) after vacuum-assisted delivery at Royal Darwin Hospital on 31 August 2007. He was stuck in the birth canal for approxim…
0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…
…r induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APGAR score (3 at 1 minute) but improved to 7 by 5 min…
0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…
…es deteriorated from 2100 hours but medical staff were not escalated to review until after 0138 hours when vacuum-assisted delivery was attempted. Lucy was born in poor condition with severe metabolic acidosis and requir…
2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…
…olonged labour with foetal tachycardia and reduced variability on CTG monitoring. After failed attempts at vacuum and forceps delivery in the birthing room, an urgent category-one caesarean section was performed. The inf…
0y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
…gistrar was off-site, 30 minutes away. At 0418 hours a significant bradycardia to 60 bpm prompted assisted vacuum delivery at 0431 hours. The infant required extensive resuscitation and died 2 days later. The coroner fou…
0y · Female·Perinatal asphyxia
Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …
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 fail…
0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…
0y · Female·Group B Streptococcus meningitis and sepsis
An 18-day-old baby died from late-onset Group B Streptococcus (GBS) meningitis and sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm)…
0y · Female·Peripartum hypoxia
Mia Davies died from peripartum hypoxia after a prolonged and poorly managed labour at Royal Brisbane and Women's Hospital. She had been diagnosed with multiple congenital anomalies (atrioventricular septal defect, oesop…
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