312 results
16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis
A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan w…
7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…
Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
2y · Female·effects of fire (smoke inhalation and thermal injury)
AW, a 2-year-old girl with 15a11.2 BP1-BP2 microdeletion syndrome and developmental delays, died on 14 April 2018 in a house fire at her rural NSW home. She died from smoke inhalation and thermal injury. The fire's exact…
0y · Female·subgaleal haematoma complicating an obstructed labour
Vanessa Li, a term infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who wa…
31y · Male·hanging
B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…
0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease
Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…
0y · Female·Sudden infant death syndrome (SIDS) category 2
Baby A, born on 6 August 2018 to a mother in remand custody at Dame Phyllis Frost Centre, died of SIDS category 2 on 18 August 2018 aged 12 days. She was born with neonatal abstinence syndrome due to maternal methadone u…
15y · Male·Hanging
A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…
17y · Male·hydrocarbon toxicity (petrol inhalation)
George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …
5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity
LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…
31y · Male·Hanging
Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …
12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …
A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…
11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…
Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…
21y · Male·Complications of blunt head injury resulting from at least two separate acts of …
Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from sig…
1y · Female·sudden cardiac death on a background of rhinovirus infection
Harriet Ostler, a 19-month-old toddler, was admitted to Port Macquarie Base Hospital with viral respiratory symptoms and died from sudden cardiac death due to underlying myocarditis/cardiomyopathy precipitated by rhinovi…
13y · Male·Hanging
Zhane Chilcott, age 13, died by suicide at a residential care facility after 12 years in state care with 18 placements. The coroner found multiple systemic failures: inadequate scrutiny of his first placement with LB des…
1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephre…
A 19-month-old girl with history of Wilms tumour presented to Launceston General Hospital with vomiting, pain and lethargy. A Children's Early Warning Tool score of 6 triggered mandatory protocols including senior doctor…
2y · Female·perforated oesophagus secondary to complications of treatment of oesophageal inj…
Callie Griffiths-I'Anson, a 2-year-old girl, died from a perforated oesophagus secondary to complications of treatment for caustic soda ingestion. She ingested caustic dishwashing liquid at a hotel on 11 December 2017 an…
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