Inquest into the death of Else COGHILL Decision of Deputy State Coroner Dillon on 11 March 2016 CATCHWORDS CORONIAL LAW – cause and manner of death, death of infant, whether antenatal arrangements were appropriate, whether augmentation of labour was appropriate, whether an operating theatre should have been made available during labour, whether a paediatrician should have been present at birth, whether immediate postnatal care was appropriate


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