29 results
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…
Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…
Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…
0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…
Jordan was born at 25 weeks 4 days gestation in an emergency department following precipitant breech labour with a circumvallate placenta. He received appropriate initial resuscitation but was administered 10 times the p…
1y · Male·acute meningitis from Streptococcus pneumoniae, associated with diffuse brain sw…
Noah Souvatzis, a 19-month-old boy, died from Streptococcus pneumoniae meningitis on 31 December 2021 after presenting to Northeast Health Wangaratta ED on 29 December. Critical failures in his first ED presentation incl…
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…
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…
6y · Male·Sepsis due to melioidosis
A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagno…
0y · Male·Head injury in the setting of labour
Baby Cai Wheeler-Trow was born at 36 weeks and 2 days following a failed instrumental delivery and emergency caesarean section. He developed a skull fracture and subgaleal haemorrhage, presenting with clinical deteriorat…
68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…
A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…
1y · Male·Hypoxic-ischaemic encephalopathy and multisystem failure in the setting of extre…
Baby B was born by emergency breech extraction in an ambulance after obstructed labour, sustaining severe hypoxic-ischaemic injury. The death was multifactorial. The mother had limited antenatal care despite known metham…
71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…
Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Pur…
1y · Female·Sepsis (Group A Streptococcus)
A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral …
49y · Male·bronchopneumonia
49-year-old male seaman died of bronchopneumonia with secondary pericarditis on a cargo vessel 30 nautical miles off Port Hedland. He developed acute abdominal pain and vomiting on 29 September 2012 and deteriorated rapi…
0y · Female·Perinatal asphyxia
Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…
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…
3y · Male·Streptococcus pyogenes group A pneumonia
Hugo Gardiner, a 3-year-old boy with fever, cough, vomiting and diarrhoea, was assessed twice at Mount Beauty Medical Centre on 23 December 2015 by GPs who diagnosed viral upper respiratory tract infection. Both doctors …
5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…
A 5-year-old boy with rheumatic heart disease and acute mitral valve regurgitation presented to Mt Isa Hospital with acute heart failure. Although initially recognised as deteriorating by the paediatrician on-call, the s…
4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…
A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic failures occurred: the initial GP failed to consi…
24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of th…
Brendan Burns, 24, died from acute hydrocephalus caused by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over…
Blunt force trauma sustained in level crossing collisions between heavy vehicles…
Coronial investigation into 26 deaths at 12 level crossing incidents in Victoria between 2002-2009, with focus on the Kerang incident (5 June 2007) where 11 train passengers died after a semi-trailer collided with a pass…
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