Aurora Doreen Maureen died four days after she was born at the Mount Gambier Hospital on November 17, 2011. The Deputy State Coroner Anthony Schapel said that the official cause of death was hypoxic brain injury and added that her mother, Ashlee Brown, faced a uterine rupture which displaced the baby and placenta into the abdominal cavity.
As Ms Brown's uterus was perforated after an earlier pregnancy, doctors decided to use labor inducing gels but this led to the mother experiencing excessively strong and frequent uterine contraction.
"I find that the administration of prostaglandin gel caused Ms Brown to experience excessively strong and frequent uterine contraction. I find that Aurora's death could have been prevented if the use of prostaglandin gels to induce Ms Brown's labour had been avoided", Mr Schapel said.