378 results
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…
0y · Female·brain death complicating head and neck injury
A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…
18y · Female·Multidrug toxicity (GHB, amphetamines, benzodiazepines)
PJQ was an 18-year-old in state care who died from multidrug toxicity (GHB, amphetamines, benzodiazepines) after being discharged early from a residential rehabilitation program. She had complex trauma history, PTSD, and…
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…
3y · Female·Effects of fire deliberately set by mother in motor vehicle
Carolyn James, a 3-year-old girl, died from the effects of fire when her mother deliberately set fire to a motor vehicle in which she, her sister, and mother were sitting. The investigation examined whether services had …
0y · Female·unascertained
A nine-month-old First Nations child (Baby Q) was killed by her psychotic father in November 2018. The family, transient and homeless, were known to child protection and police in NSW and Queensland with complex mental h…
13y · Female·complications of a head injury sustained when she deliberately stepped in front …
A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinici…
11y · Male·unascertained
An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…
6y · Unknown·methadone toxicity
A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…
13y · Unknown·Drowning
A 13-year-old child in state care died by drowning at Cedar Creek Falls on 8 April 2021. The coroner found that the youth worker Mr La's decision-making was reasonable, including not using physical restraint when the boy…
22y · Female·Complications of cutaneous burns
A 22-year-old woman from Afghanistan died from complications of severe burns (75%+ body surface area) sustained during self-immolation on 5 February 2018. She was experiencing family violence from her husband and in-laws…
13y · Male·Hanging
Lachlan John Howe, aged 13, died by hanging at his home on 18 May 2018 after being transported to Royal Children's Hospital. He had experienced significant family violence from his father, including emotional abuse, cont…
0y · Female·Head injury
Lily Grace Arbuckle, a 9-week-old infant, died from head injury sustained when her mother placed her on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and …
0y · Female·Unascertained
Baby ZCZ, almost 15 weeks old, died of unascertained cause after being placed to sleep in a Fisher Price rocker at an unapproved home childcare service. Post-mortem examination including neuropathology, toxicology, bioch…
32y · Female·Unknown
Tina Louise Greer, 32, disappeared on 18 January 2012 and is presumed deceased, killed by her partner Leslie Sharman who was involved in her coercive and controlling relationship, including domestic violence. The coroner…
16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis
A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan w…
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…
4y · Female·Drowning
A 4-year-old girl from an Afghan refugee family drowned in Lysterfield Lake after entering the water during a brief lapse of supervision. She was unable to swim and had not received water safety education. Despite immedi…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.