368 results
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…
2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection
A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…
0y · Male·Severe acute dehydration and acute malnutrition
An eight-month-old boy died from severe acute dehydration and malnutrition after receiving no or minimal fluid or food intake during a three-day drug binge by his mother and her partner. Child Safety was involved with th…
3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…
Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…
Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…
Two premature infants died from unsafe sleeping environments while in the care of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay i…
3y · Male·unascertained
KP was a 3-month-old with intrauterine growth restriction born to a mother with documented mental health issues and cannabis use. Despite referral to SAFE START and child protection involvement, care coordination and fol…
4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection
A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…
2y · Female·sequelae of blunt force head and spinal cord injuries
DB, aged 2 years 9 months, died from blunt force head and spinal cord injuries inflicted by her mother's boyfriend after DCJ closed its case in August 2015. The coroner found DCJ made multiple critical failures: acceptin…
0y · Male·Unascertained in the setting of a remote head injury
Child A, a six-month-old Aboriginal boy, died from unascertained cause in the setting of a remote head injury sustained during family violence. The father violently assaulted the mother while holding the child unsupporte…
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172 and 168 bpm) on 15 Sep…
1y · Female·complications of acute bronchiolitis arising from Respiratory Syncytial Virus (R…
A 17-month-old First Nations child died from acute bronchiolitis due to respiratory syncytial virus (RSV) infection in inadequate accommodation following parental separation from domestic violence services. The coroner i…
15y · Female·hanging
Harmony, a 15-year-old girl, died by hanging at a motel on 14 January 2020 in circumstances of longstanding neglect, family violence and school disengagement. The coroner found multiple systemic failures: DCJ closed case…
15y · Male·Combined heroin and methamphetamine toxicity
T, a 15-year-old boy subject to a Care by Secretary Order, died from combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), …
18y · Male·Heroin toxicity
Edward Grant Harris, an 18-year-old with autism spectrum disorder, ADHD, and borderline intellectual function, died from heroin toxicity in his supported accommodation. He had a complex history of behavioural challenges,…
0y · Male·Concussive brain injury
A 7-month-old boy died from concussive brain injury caused by intentional head trauma inflicted by his mother's partner in a domestic violence context. The child had multiple bruises, bite marks, and subdural haemorrhage…
0y · Male·Hypoxic ischaemic encephalopathy due to an out of hospital cardiac arrest second…
A 10-month-old boy drowned in a backyard fishpond after a 27-minute period of inadequate supervision. He was found unresponsive by his aunt and underwent prolonged resuscitation, suffering severe hypoxic brain injury. De…
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…
A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…
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