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VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

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…

neonatologyobstetricsmedicationdiagnosticmorphine
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…

general practicepsychiatrymedicationdiagnosticcodeine
WAhospital2023-11-17

Inquest into the Death of Child MD (Name Subject to a Suppression Order)

2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…

A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…

intensive carepaediatricsmedicationceftriaxone
WAhome2023-11-10

Inquest into the Death of Child ML (Name Subject to Suppression Order)

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…

paediatricsrespiratory medicinemedicationsystemcodeine
NSWhome2022-03-30

Inquest into the deaths of Stacey DOCHERTY and Seth DOCHERTY

38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…

Stacey Docherty, a 38-year-old woman with complex post-traumatic stress disorder and borderline personality disorder resulting from childhood sexual abuse, killed her 3-year-old son Seth before taking her own life in Mar…

psychiatrygeneral practicemedicationcommunicationalprazolam
NSWhome2021-12-20

Inquest into the death of Harland SUTTON

5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained

A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…

paediatricsemergency medicinesystemmedicationfurosemide
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
WAhome2019-06-12

Inquest into the Death of Child L (Name Subject to Suppression Order)

13y · Male·Epileptic seizure with aspiration

Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…

neurologypaediatricsmedicationcommunicationlevetiracetam
QLDhospital2018-09-21

Baby M

0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…

Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nur…

obstetricsmidwiferydiagnosticmedicationantibiotics
VIChospital2015-07-15

Finding into death of Baby Mabel Windmill

0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…

Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…

obstetricsanaesthesiadiagnosticmedicationbenzylpenicillin
QLDhome2015-04-24

Lievesley, Tamiya Calais

0y · Female·Morphine toxicity

Tamiya Calais Lievesley, a six-month-old infant, died from morphine toxicity on 2 March 2004. She ingested a fatal dose of morphine, likely administered by one of her parents who were both morphine-dependent. The coroner…

paediatricsgeneral practicemedicationdiagnosticmorphine
NThospital2012-03-28

Inquest into the death of Master F

17y · Male·pneumonia and respiratory failure associated with choreoathetoid cerebral palsy

A 17-year-old Indigenous male with severe choreoathetoid cerebral palsy, feeding difficulties, and swallowing dysfunction died of pneumonia and respiratory failure in ICU. He had missed lunch medications (Baclofen and Ga…

general surgerypaediatricsmedicationbaclofen
VIChome2011-04-15

Finding into death of Elanur Koc

2y · Female·pneumonia in a toddler with enlarged tonsils and presence of codeine in blood

Elanur Koc, a 2-year-old with a history of recurrent throat infections and enlarged tonsils, died from pneumonia. Significant codeine was detected in her blood, urine, liver, and stomach contents, with codeine also prese…

paediatricsgeneral practicemedicationcodeine

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