158
Total cases
78%
Preventable or possibly preventable
85%
With coroner recommendations
59%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
0y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant
Baby H died on 24 March 2019, one day after birth, from traumatic head injuries sustained during an instrumental vaginal delivery using Neville Barnes forceps on a baby in occipito-posterior position. Critical clinical l…
0y · Male·Perinatal hypoxia
Baby R, born at 39 weeks 6 days via planned homebirth with private midwives, died from perinatal hypoxia on day 6 of life. The mother had significant obstetric risk factors: previous emergency caesarean section, macrosom…
0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…
Lucy Margaret Campbell died eight days after birth from severe hypoxic ischemic encephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneo…
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…
0y · Male·Complications following forceps delivery
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…
0y · Female·Perinatal asphyxia
Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…