Coronial
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NSWhome2023-10-24

Inquest into the death of AW

2y · Female·effects of fire (smoke inhalation and thermal injury)

AW, a 2-year-old girl with 15a11.2 BP1-BP2 microdeletion syndrome and developmental delays, died on 14 April 2018 in a house fire at her rural NSW home. She died from smoke inhalation and thermal injury. The fire's exact…

paediatricssocial worksystemdelay
TAShome2023-10-19

Coroner's Finding: de-identified FG

0y · Male·suffocation due to overlay by a sleeping adult

A 59-day-old premature infant died from suffocation due to overlay by a sleeping parent. The infant was placed on a mattress next to the parent's cot after refusing to settle in his own cot. Despite the parent's attempt …

paediatricsneonatologysystem
VIChome2023-10-17

Finding into death of J H

15y · Male·Electrocution

JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient p…

psychiatrypaediatricssystemcommunicationfluoxetine
NSWhome2023-09-08

Inquest into the death of BW

31y · Male·hanging

B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…

paediatricspsychiatrycommunicationsystemalcohol
SAhospital2023-08-30

Coroner's Finding: Fergusson, Logan Scott

0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease

Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…

cardiologypaediatricsdelaydiagnosticheparin
VIC2023-08-30

Finding into death of Baby A

0y · Female·Sudden infant death syndrome (SIDS) category 2

Baby A, born on 6 August 2018 to a mother in remand custody at Dame Phyllis Frost Centre, died of SIDS category 2 on 18 August 2018 aged 12 days. She was born with neonatal abstinence syndrome due to maternal methadone u…

neonatologypaediatricssystemcommunicationmethadone
NSWcommunity2023-08-25

Inquest into the death of SG

15y · Male·Hanging

A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…

psychiatrypaediatricscommunicationsystem
NSWhome2023-08-22

Inquest into the death of George Campbell

17y · Male·hydrocarbon toxicity (petrol inhalation)

George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …

paediatricspsychiatrycommunicationsystempetrol
NSWhome2023-08-15

Inquest into the death of LA

5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity

LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…

paediatricsintensive caredelaycommunicationmethadone
VIChome2023-07-27

Finding into death of Mr A

31y · Male·Hanging

Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …

psychiatrygeneral practicesystemcommunicationmethamphetamine
VIChospital2023-07-17

Finding into death of Sasha

12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …

A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …

paediatricsinfectious diseasescommunicationsystem
WAhospital2023-07-07

Inquest into the Death of Ashlee Jade REINDL

0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…

Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…

obstetricsmidwiferydiagnosticcommunicationoxytocin
WAhospital2023-06-29

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

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…

paediatricsemergency medicinediagnosticcommunicationmacrogol
NSWhospital2023-06-23

Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of …

Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from sig…

paediatricsemergency medicinediagnosticcommunication
VIChospital2023-05-29

Finding into death of Kaleb Baylis-Clarke

0y · Male·Head injury in the setting of chronic subdural haemorrhage

Kaleb Baylis-Clarke, a 17-week-old infant, presented to hospital on 14 January 2016 with a head lump, vomiting, raised fontanelle and reduced milk intake. Cranial ultrasound showed fluid in subdural spaces. MRI on 15 Jan…

paediatricsneurosurgerysystem
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
NSWhospital2023-05-09

Inquest into the death of Harriet Ostler

1y · Female·sudden cardiac death on a background of rhinovirus infection

Harriet Ostler, a 19-month-old toddler, was admitted to Port Macquarie Base Hospital with viral respiratory symptoms and died from sudden cardiac death due to underlying myocarditis/cardiomyopathy precipitated by rhinovi…

paediatricsemergency medicinediagnosticcommunicationsalbutamol
SA2023-04-06

Coroner's Finding: Chilcott, Zhane Andrew Keith

13y · Male·Hanging

Zhane Chilcott, age 13, died by suicide at a residential care facility after 12 years in state care with 18 placements. The coroner found multiple systemic failures: inadequate scrutiny of his first placement with LB des…

paediatricsgeneral practicesystemcommunication
TAShospital2023-04-03

Coroner's Finding: RS - de-identified

1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephre…

A 19-month-old girl with history of Wilms tumour presented to Launceston General Hospital with vomiting, pain and lethargy. A Children's Early Warning Tool score of 6 triggered mandatory protocols including senior doctor…

emergency medicinepaediatricsdiagnosticsystem
VIChospital2023-03-31

Finding into death of Callie Griffiths-I'Anson

2y · Female·perforated oesophagus secondary to complications of treatment of oesophageal inj…

Callie Griffiths-I'Anson, a 2-year-old girl, died from a perforated oesophagus secondary to complications of treatment for caustic soda ingestion. She ingested caustic dishwashing liquid at a hotel on 11 December 2017 an…

paediatric surgeryanaesthesiacommunicationsystemmidazolam
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