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QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…

neonatologypaediatricsdiagnosticcommunication
VIChospital2024-11-22

Finding into death of RD Z

11y · Male·complications of bowel obstruction in the setting of chronic constipation

RDZ was an 11-year-old Aboriginal boy who died from complications of bowel obstruction secondary to chronic constipation with a fecalith. He had been under paediatric care for years with multiple admissions for bowel was…

gastroenterologypaediatric surgerydiagnosticcommunicationmacrogol
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
NSWhospital2024-05-10

Inquest into the death of Finlay Browne

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…

emergency medicinesurgerydiagnosticcommunication
VIChospital2023-10-30

Finding into death of BCT

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…

gastroenterologyradiologydiagnosticcommunicationceftriaxone
TAShospital2023-04-03

Coroner's Finding: RS - de-identified

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…

emergency medicinepaediatricsdiagnosticsystem
TAShome2022-02-18

Coroner's Finding: FL de-identified

17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest

FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriora…

paediatric surgerygastroenterologydiagnosticdelay
NSWhospital2019-12-13

Inquest into the death of Luca RASO

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)…

general practiceemergency medicinediagnosticcommunication
NSWhospital2019-05-14

Inquest into the death of Shaun BELL

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…

emergency medicinepaediatricsdiagnosticcommunication
VIChome2017-04-06

Finding into death of Child W

10y · Female·Ischaemic large bowel; large bowel obstruction secondary to chronic constipation

Child W, aged 10, died from ischaemic large bowel secondary to chronic constipation and faecal impaction. She had lifelong constipation and encopresis (soiling) from infancy, presenting to her GP twice (2008, 2010) with …

paediatricsgeneral practicediagnosticdelaymacrogol
NSWhospital2016-12-21

Inquest into the death Kyran DAY

0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…

Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…

paediatricsemergency medicinediagnosticcommunication
QLDhospital2016-05-06

Sweet, Lilli

6y · Female·Brain stem herniation due to pneumococcal meningitis

Lilli Sweet, a 6-year-old asplenic child with hereditary spherocytosis, died from pneumococcal meningitis with brain stem herniation. She presented to Nambour Hospital ED with vomiting, diarrhea, and headache on 25 Augus…

paediatricsemergency medicinediagnosticcommunicationparacetamol
VIChome2014-03-17

Finding into death of Marcus Michael Christopher Charles

0y · Male·Complications of small bowel obstruction due to post operative adhesions

Marcus Charles, a 3-month-old neonate, died from small bowel obstruction due to postoperative adhesions following earlier surgical repair of oesophageal atresia and duodenal atresia. On 4 November 2006, paramedics attend…

emergency medicineparamedicinediagnosticcommunicationranitidine
WAhospital2012-10-05

Inquest into the Death of Rasmussen vaughn

15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…

Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …

general practicegeneral medicinediagnosticcommunicationlamotrigine
NSWhospital2011-08-15

Coroner's Finding: Jacob Leonel Belim

8y · Male·Septic shock consequent on burst appendix with peritonitis

Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…

emergency medicinegeneral practicediagnosticcommunicationampicillin
VIChospital2011

Finding into death of ALYSSA TZE SIM CHAN

Female·Combination of liver failure, blood loss and shock following needle biopsy

Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…

gastroenterologyanaesthesiadiagnosticproceduralphytomenadione
SAhospital2010-09-27

Coroner's Finding: ORMEROD Madison Hayley

4y · Female·consequences of incarcerated congenital left diaphragmatic hernia

Madison Ormerod, aged 4 years, died from incarcerated congenital left diaphragmatic hernia. Over 3 months before death, she presented with persistent vomiting and abdominal pain to her GP and paediatrician. The paediatri…

general practicepaediatricsdiagnosticdelay
QLDhospital2005-05-04

Robinson, Jacinta Kate

7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…

A 7-year-old girl with spina bifida died from cardiac tamponade caused by total parenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clini…

paediatric surgeryanaesthesiadiagnosticcommunicationtotal parenteral nutrition
ACThospital1998-07-16

Inquest Into The Death Of Nathan Thomas James Wrench

0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…

Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…

paediatric surgeryemergency medicinecommunicationdiagnostic

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