368 results
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
Multiple causes: Child 1 - blunt force trauma to chest and abdomen; Child 2 - he…
This cluster inquest examined four Victorian child deaths (2015-2017) involving parents' partners as perpetrators. Children 1-4 died from blunt force trauma, head injury, fire, and neck laceration respectively. Key syste…
Female·Domestic violence homicides: Miss Yunupiŋu—stab wound to chest; Ngeygo Ragurrk—b…
This landmark coronial finding examines four domestic violence deaths of Aboriginal women in the Northern Territory—Miss Yunupiŋu (2018), Ngeygo Ragurrk (2019), Kumarn Rubuntja (2021), and Kumanjayi Haywood (2021)—all ki…
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…
2y · Male·Pneumonia
A 2-month-old Aboriginal infant died of pneumonia on 17 July 2019. Key clinical lessons: (1) Fever in infants <3 months requires careful evaluation per RCH guidelines, including investigations and admission for observati…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
1y · Male·Pneumonia (early-onset, caused by Group B Streptococcus)
Baby XR died at one day old from early-onset pneumonia caused by Group B Streptococcus (GBS) acquired during vaginal delivery. The mother had known GBS colonisation and received intrapartum prophylactic antibiotics as pe…
49y · Female·stab wound to the neck
Noeline Dalzell, a 49-year-old Aboriginal woman, was fatally stabbed in the neck by her partner James Fairhall on 4 February 2020 after 17 years of escalating family violence. Multiple systems failed to protect her and h…
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…
9y · Female·Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl wi…
Makayla Lee Wadeson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms on 29 July 2022. She was triaged Category 4 and disc…
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…
14y · Male·Brain infarction caused by hypoxia following self-inflicted hanging by rope liga…
PT was a 14-year-old boy with a history of anorexia nervosa and bulimia who died by hanging in April 2022. He had been discharged from eating disorder treatment in November 2021 after maintaining appropriate weight. In t…
23y · Female·stab wound of the chest
Kunmanara May, aged 23, was killed by her partner SK in a domestic violence homicide in 2015. Multiple agencies—South Australia Police, Families SA, Aboriginal Family Support Service, and Centacare—knew of escalating vio…
1y · Female·viral respiratory tract infection (Parainfluenza and Respiratory Syncytial Virus…
Matilda Armstrong, a 12-month-old previously well child, died from viral respiratory tract infection (Parainfluenza and RSV) complicated by Streptococcus pyogenes sepsis following recent COVID-19 infection. She presented…
0y · Female·hyperviscosity-related brain injury secondary to hypernatraemic dehydration
Siya Patel, a 23-day-old neonate, died from hyperviscosity-related brain injury secondary to severe dehydration caused by insufficient breastfeeding. Her family were recent emigrants without Medicare eligibility, creatin…
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…
0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…
Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …
13y · Female·Self-inflicted single gunshot wound to the chest
Grace, 13, died from a self-inflicted gunshot wound using an unsecured .308 Winchester rifle stored in her parents' bedroom. She had disclosed suicidal thoughts to a school counsellor in September 2021, but this disclosu…
17y · Female·Neck compression by hanging (suicide)
XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …
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…
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