Demographics
15y, female
Date of death
2013-03-23
Finding date
2013-12-18
Cause of death
cardiac and respiratory arrest following pulmonary aspiration
AI-generated summary
Miss M, a 15-year-old Aboriginal girl with severe cerebral palsy and multiple medical complications, died from cardiac and respiratory arrest due to pulmonary aspiration. She had an Advance Care Directive (ACD) in place specifying no CPR, but resuscitation was initiated by carers and continued by ambulance and hospital staff, who were unaware of the ACD at the time. The coroner found the resuscitation appropriate given the acute presentation and potential for treatable airway obstruction. A key gap identified was that the ACD was not prominently placed in her medical file, making it difficult to locate during emergencies. The coroner noted that Katherine Hospital has since implemented education to ensure ACDs and care plans are kept at the front of files. Additionally, the coroner highlighted that medical staff failed to initially recognize this death as reportable due to the deceased's status as a child in care, emphasising the mandatory reporting requirement for such deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…
Lucy Margaret Campbell died eight days after birth from severe hypoxic ischemic encephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneo…
Sudden Unexplained Death of an Infant (SUDI) in an unsafe sleeping environment; …
Three Aboriginal infants died in unsafe co-sleeping environments in the Northern Territory. Baby K (3 months), Baby B (2 months), and Baby S (5 weeks) all died from sudden unexpected death in infancy (SUDI) associated wi…
33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…
F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —