115 results
Sudden Unexplained Death of an Infant (SUDI) in an unsafe sleeping environment; …
Three Aboriginal infants died in unsafe co-sleeping environments in the Northern Territory. Baby K (3 months), Baby B (2 months), and Baby S (5 weeks) all died from sudden unexpected death in infancy (SUDI) associated wi…
1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…
Serena Lee, born 31 October 2021, died at 2 months from obstructive sleep apnoea in the context of severe, unrecognised hypoglycaemia associated with intrauterine growth restriction (IUGR). She was discharged from Campbe…
32y · Female·Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystit…
A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty p…
2y · Male·Complications of malnutrition
GFD, a 2-year-old boy, died from complications of malnutrition and dehydration on 3 July 2021. Post-mortem examination revealed severe undernutrition, chronic malnutrition, and significant dehydration with hypernatraemia…
32y · Female·Head injuries in a motor vehicle incident
Helena Zoe Broadbent, a 32-year-old pregnant Aboriginal woman, died from severe head injuries sustained when her partner William Wilson drove off in a vehicle while she was partially inside it, causing her to be ejected …
0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
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…
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…
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…
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…
0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…
Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged …
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…
31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…
A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…
0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …
Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …
Female·Hypoxic ischaemic encephalopathy due to hanging
Ms S died by suicide while experiencing severe postnatal depression eight weeks after giving birth. She presented to the ED with anxiety, insomnia, and suicidal ideation and was admitted to the Logan Hospital Mental Heal…
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…
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 …
1y · Female·Neonatal pneumonia, meconium aspiration and chorioamnionitis secondary to prolon…
Baby E died at home one day after birth at 40+ weeks gestation following a prolonged labour in a hired plastic birthing pool. The mother had no antenatal care, no midwifery support, and her Group B Streptococcus status w…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.