Inquest into the death of baby Everett Carleton

Case Number: 2018/245959

Findings Date: 12 April 2024

Magistrate: Carmel Forbes

CORONIAL LAW | cause and manner of death of a baby at birth; ultrasound report;  continuous CTG monitoring caesarean section; separation of the umbilical cordtransected placenta-NICU response

Responses

Recommendations

Director of the South Western Sydney Local Health District

1. I recommend that the SWSLHD consider including the measurement of the estimated distance from the leading edge of the placenta to the internal os where relevant to the planning and management of a surgical delivery.

2. I recommend that the SWSLHD consider taking steps to ensuring that a supply of 0 negative blood is readily available for use in theatres in which caesarean sections are performed.

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