Demographics
3y, female
Coroner
Decision ofDeputy State Coroner Lee
Date of death
2005-02-09
Finding date
2017-12-01
Cause of death
peritonitis caused by small bowel perforation due to blunt force trauma
AI-generated summary
A 3-year-old girl died from peritonitis caused by small bowel perforation. Expert evidence established the perforation resulted from blunt force trauma, not natural disease or accidental mechanisms. The manner of injury (accidental vs. inflicted) could not be determined, though the timing (2-7 days before death) and mechanism were consistent with significant blunt force. Critical systemic issues were identified: the child's identical twin had presented to hospital months earlier with serious intracranial injuries of unknown mechanism; child protective services investigated but failed to adequately assess risk or complete required assessments before the deceased's death. Current statutory agencies have since implemented substantial improvements including mandatory ROSH categorization, escalation protocols, safety assessment tools, and follow-up compliance mechanisms that would prevent similar failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…
Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…
13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis
Luca Raso, a healthy 13-year-old boy, died from peritonitis secondary to ruptured gangrenous acute appendicitis after being misdiagnosed with viral gastroenteritis by his GP on two consultations (22 and 24 February 2017)…
4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer
A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglob…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.