190
Total cases
84%
Preventable or possibly preventable
91%
With coroner recommendations
65%
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…
Sudden Unexplained Death of an Infant (SUDI) in an unsafe sleeping environment; …
Three Aboriginal infants died in unsafe co-sleeping environments in the Northern Territory. Baby K (3 months), Baby B (2 months), and Baby S (5 weeks) all died from sudden unexpected death in infancy (SUDI) associated wi…
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…
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…