Coroner Court Recommendations

6 July 2010

As a result of a coronial inquest into the deaths of two babies, Jessica Stemmer and Thomas Mahar, the State Coroner of South Australia has recommended that the Nursing and Midwifery Board of Australia draw the circumstances of these cases to the attention of the nursing and midwifery professions.

The Coroner found that Jessica Stemmer, aged seven hours, died as a result of disseminated intravascular coagulation following haemorrhage and Thomas Mahar, aged eight days, died as a result of multiorgan failure and coagulopathy, following haemorrhage and hypoxia.

Among the recommendations for both these cases it was identified that practitioners need to recognise that:

  • subgaleal haemorrhages can behave in unpredictable ways and can have devastating consequences.
  • undue reliance should not be placed upon a clinical picture of haemodynamic stability alone as the clinical picture may be falsely reassuring.
  • upon diagnosis of subgaleal haemorrhage in a neonate, practitioners should have regard to the potential need for cross matched blood transfusion and transfusion of fresh frozen plasma. They should immediately take the necessary steps to ensure that cross matched blood and fresh frozen plasma is available to be administered at short notice.

The full findings of the Coroner’s Court and its recommendations, which were delivered on 6 July 2010, can be accessed on the Courts Administration Authority, South Australia’s website.

Page reviewed 6/08/2014