23 results
32y · Female·Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystit…
A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty p…
<1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…
Serena Lee, born 31 October 2021, died at 2 months from obstructive sleep apnoea in the context of severe, unrecognised hypoglycaemia associated with intrauterine growth restriction (IUGR). She was discharged from Campbe…
<1y · Female·Unascertained
An unnamed full-term baby was found deceased at Edmondson Park on 19 February 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's existence. Po…
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…
<1y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …
Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …
<1y · Female·Methylamphetamine toxicity
A newborn baby died 8 hours after birth from methylamphetamine toxicity acquired in utero. The mother unknowingly consumed methylamphetamine in the days before labour, likely by drinking from a contaminated bottle at a r…
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…
<1y · Male·neonatal encephalopathy due to perinatal compromise
Jaxon McGrorey-Smith, a full-term neonate, was delivered by caesarean section after prolonged labour. He developed seizures and signs of hypoxic-ischaemic encephalopathy (HIE) within hours of birth, with MRI imaging conf…
<1y · Female·Hypoxia resulting from primary idiopathic pulmonary hypertension of the newborn …
Jasmine Chiang died at 7 hours of age from primary idiopathic pulmonary hypertension of the newborn (PPHN), probably complicated by pulmonary haemorrhage. She presented with classic PPHN signs (harlequin appearance, diff…
<1y · Female·ischaemic hypoxic encephalopathy secondary to factors associated with the sudden…
Manusiu Amone died from ischaemic hypoxic encephalopathy secondary to persistent pulmonary hypertension of the newborn (PPHN), not from pethidine toxicity as initially suspected. At 145 minutes of life, she developed gas…
26y · Female·sepsis
Michaela Perrin, 26, died from sepsis arising from a post-caesarean wound infection caused by MRSA on 22 October 2014. She presented to the Emergency Department on 20 October with severe pain, tachycardia (125 bpm), and …
20y · Female·unascertained
Alyce Pollett, a 20-year-old pregnant woman, was found dead in her bed on 14 July 2011 after being unwell for approximately one week with flu-like symptoms. Autopsy findings were concerning for possible asphyxia due to n…
46y · Female·acute mixed drug toxicity due to accidental self-administered drug overdose
Dr V., an obstetrician-gynaecologist trainee, died from acute mixed drug toxicity on 18 January 2013 following self-administration of multiple anaesthetic drugs (propofol, midazolam, fentanyl, alfentanil) via intravenous…
<1y · Male·Hypoxic ischaemic encephalopathy (brain damage) sustained during and just after …
A newborn died from hypoxic-ischaemic encephalopathy following a home birth without medical assistance. The mother had significant risk factors: hepatitis C, anaemia, and transverse fetal lie confirmed at 38+ weeks gesta…
<1y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…
Elsie Coghill, a newborn, died from hypoxic ischaemic encephalopathy due to multiple factors including an underlying lung abnormality from antenatal distress, an undetected apnoeic episode during transfer, and undiagnose…
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…
<1y · Female·Hypoxic episode, probably caused by cord entanglement during delivery
A neonate (Roisin) died within 90 minutes of unattended home birth on 27 March 2009. The mother, Janet Fraser, is an advocate for natural birth and rejected all antenatal care despite risk factors including previous caes…
29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…
Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely cephalosporin-triggered) with car…
14y · Female·Neisseria meningitidis infection (meningococcal septicaemia)
A 14-year-old girl presented to Gosford Hospital Emergency Department on 4 December 2007 with high fever (40°C), headache, vomiting, myalgia, and haemodynamic instability (hypotension, tachycardia, tachypnoea)—all signs …
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
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