368 results
2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…
Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…
0y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart ra…
1y · Male·Complication of burns and trauma to the mesenteric artery
A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…
0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…
Owen Appleby, born at Portland Hospital after labour induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APG…
14y · Male·injuries sustained in fall from height
Aaron, aged 14, died by suicide from a fall from an 11th-floor balcony. Over 12 years, he had 14 child protection notifications for exposure to domestic violence, neglect, parental substance misuse, poor school attendanc…
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …
2y · Female·drowning
A 2-year-old girl drowned in a backyard swimming pool after gaining access through a sliding security door with a deliberately disabled lock. The father had tampered with and rendered non-functional the locking mechanism…
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…
16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …
A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…
2y · Male·Hypoxic Ischaemic Brain Injury in circumstances of Ligature strangulation (Blind…
Lachlan McCann, a healthy 2-year-old, died from hypoxic ischaemic brain injury following ligature strangulation by a blind cord. While playing on a couch beneath a window, he became entangled in an unsecured Holland blin…
2y · Female·compression of the neck as a result of having become entangled in a blind cord
Rosalind Smith, a healthy 2-year-old, died from neck compression after becoming entangled in a Holland blind cord while attempting to look out a bedroom window. The cord was unsecured and hung at 870mm from the floor, ac…
13y · Female·cardiac arrest resulting from dehydration
A 13-month-old girl with short bowel syndrome died from cardiac arrest due to severe dehydration. She had been deteriorating with diarrhoea and vomiting on 18 February 2009, prompting nursing staff to escalate concerns t…
15y · Female·Ligature compression of the neck (hanging)
A 15-year-old Aboriginal girl died by suicide by hanging on 29 November 2007. She had a transient lifestyle with unstable housing, moved frequently between relatives, was not regularly attending school, and engaged in su…
12y · Female·acute septicaemia resulting from osteomyelitis of the left femur
A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…
0y · Male·failure to thrive due to insufficient caloric intake
Kalib died from failure to thrive due to insufficient caloric intake at 7 weeks old. He was born to a mother with a documented history of severe neglect and physical abuse of multiple children over 5 years, during which …
14y · Female·hanging
Sharkia Handy, a 14-year-old girl in out-of-home care, died by hanging in December 2007. She had significant unaddressed mental health concerns including suicidal ideation, self-harm, and grief following peer suicides. T…
14y · Male·gunshot wound to the head
Andrew Scott Anderson was a 14-year-old boy placed in Department of Child Safety care following his father's physical assault. He had a longstanding history of behavioral difficulties, ADHD, depression, and substance use…
15y · Female·Hanging (self-inflicted)
A 15-year-old Aboriginal girl in a remote Central Australian community died by suicide following a year marked by petrol sniffing, sexual abuse concerns, and reported suicide attempts. She suffered multiple sexually tran…
0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery
Declan Brian McConville was born with shoulder dystocia (impacted shoulders) after vacuum-assisted delivery at Royal Darwin Hospital on 31 August 2007. He was stuck in the birth canal for approximately 15 minutes before …
10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media
Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seei…
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