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QLDhospital2026-05-07

Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischaemic encephalopathy, result of brain injury as a consequence…

Lucy Campbell, a neonate born on 16 February 2024, died from severe hypoxic ischaemic encephalopathy following a complicated assisted vaginal birth at a rural level 3 hospital. The mother underwent induction of labour at…

obstetricsobstetricsdiagnosticcommunicationoxytocin
NThome2026-04-30

Inquest into the death of Baby S, Baby K, Baby B - (Co Sleeping)

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…

paediatricsmidwiferycommunicationsystemalcohol
NSWhospital2026-03-17

Inquest into the death of Serena Lee

1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…

Serena Lee, born 31 October 2021, died at 2 months from obstructive sleep apnoea in the context of severe, unrecognised hypoglycaemia associated with intrauterine growth restriction (IUGR). She was discharged from Campbe…

neonatologymidwiferydiagnosticsystem
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
VIChospital2025-09-29

Finding into death of Baby M

0y · Female·Perinatal asphyxia

Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…

obstetricsneonatologyproceduralcommunicationadrenaline
VIChome2025-09-12

Finding into death of Baby H

0y · Female·Unascertained

Baby H was born at home on 21 September 2022 following an unassisted birth (freebirth) without medical oversight. The mother had received no antenatal care despite being unaware of the actual gestational age. The baby sh…

obstetricsneonatologydiagnosticdelay
NSWhome2025-09-04

Inquest into the death of Baby MA

0y · Female·Unascertained

An unnamed full-term baby was found deceased at Edmondson Park on 19 February 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's existence. Po…

obstetricsemergency medicinedelay
VIChome2025-08-20

Finding into death of GFD

2y · Male·Complications of malnutrition

GFD, a 2-year-old boy, died from complications of malnutrition and dehydration on 3 July 2021. Post-mortem examination revealed severe undernutrition, chronic malnutrition, and significant dehydration with hypernatraemia…

paediatricsforensic medicinesystemcommunication
VIChospital2025-07-22

Finding into death of Helena Zoe Broadbent

32y · Female·Head injuries in a motor vehicle incident

Helena Zoe Broadbent, a 32-year-old pregnant Aboriginal woman, died from severe head injuries sustained when her partner William Wilson drove off in a vehicle while she was partially inside it, causing her to be ejected …

emergency medicinetrauma surgerycommunicationsystemcannabis
VIChospital2025-07-14

Finding into death of Baby Sidney

0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…

Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …

obstetricsneonatologydiagnosticcommunicationoxytocin
VIChospital2025-02-20

Finding into death of Mia Rose Iskander

0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…

Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…

obstetricsneonatologydiagnosticdelayamoxicillin
VIChospital2025-01-29

Finding into death of Amir Mohammad Iran

2y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax

A 2-day-old term infant (2670g, small-for-gestational-age) presented with respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensatio…

neonatologyobstetricsdiagnosticdelaysurfactant
NThospital2024-12-06

Inquest into the death of Baby G

0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…

Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…

neonatologypaediatricsdiagnosticsystem
NSW2024-10-24

Inquest into the death of Fiona Goodberg

36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…

Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…

psychiatrygeneral practicediagnosticcommunicationescitalopram
ACThospital2024-09-11

Inquest Into The Death Of Baby X

0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…

Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged …

obstetricsneonatologydiagnosticcommunication
VIChome2024-08-19

Finding into death of Siya Yogin Patel

0y · Female·hyperviscosity-related brain injury secondary to hypernatraemic dehydration

Siya Patel, a 23-day-old neonate, died from hyperviscosity-related brain injury secondary to severe dehydration caused by insufficient breastfeeding. Her family were recent emigrants without Medicare eligibility, creatin…

neonatologygeneral practicediagnosticcommunication
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…

general practiceobstetricscommunicationsystemmethamphetamine
NSWhospital2024-04-12

Inquest into the death of Everett Carleton

0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …

Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …

obstetricsneonatologycommunicationprocedural
VIChome2024-02-05

Finding into death of Ms KSI

22y · Female·Complications of cutaneous burns

A 22-year-old woman from Afghanistan died from complications of severe burns (75%+ body surface area) sustained during self-immolation on 5 February 2018. She was experiencing family violence from her husband and in-laws…

general practiceemergency medicinecommunicationsystem
VIChospital2024-01-18

Finding into death of Lily Grace Arbuckle

0y · Female·Head injury

Lily Grace Arbuckle, a 9-week-old infant, died from head injury sustained when her mother placed her on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and …

obstetricspaediatricsdiagnosticcommunication

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