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NSWchildcare2026-05-06

Inquest into the death of Arianna Maragol

1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…

Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…

paediatricsemergency medicinesystemcommunicationibuprofen
NThome2026-04-30

Inquest into the death of Baby S, Baby K, Baby B - (Co Sleeping)

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…

paediatricsmidwiferycommunicationsystemalcohol
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…

psychiatrypaediatricsdiagnosticsystem
NThome2026-03-20

Inquest into the death of Ralph Donald

35y · Male·self-inflicted gunshot wound to the head

Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…

psychiatryaddiction medicinesystemcommunication
NSWhospital2026-03-17

Inquest into the death of Serena Lee

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…

neonatologymidwiferydiagnosticsystem
NSWhospital2026-02-26

Inquest into the death of Jeremy Webb

16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…

Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline
WAhospital2026-02-23

Inquest into the Death of Child MML

11y · Male·bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…

An 11-year-old Aboriginal boy died from bronchopneumonia and small bowel necrosis with perforation, following severe neurological impairment from an inflicted brain injury sustained at 8 months old. His parents delayed s…

neurologypaediatricscommunicationsystem
WAhome2025-12-22

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

14y · Male·epilepsy in a boy with Influenza B and COVID-19 infections

A 14-year-old Aboriginal boy with newly diagnosed epilepsy died unexpectedly on 24 August 2023 after an unwitnessed seizure while sleeping at his residential care home. He had been diagnosed with epilepsy in June 2023 fo…

paediatricsneurologycommunicationsystemsodium valproate
WA2025-12-17

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

14y · Female·ligature compression of the neck (hanging); suicide

A 14-year-old girl in state care (Child RK) died by suicide on 20 April 2022. She had complex presentations stemming from early childhood trauma, including attachment difficulties, emotional dysregulation, self-harm, sui…

psychiatrypsychologycommunicationsystemmelatonin
VIChome2025-10-28

Finding into death of HCG

39y · Female·Unascertained

A 39-year-old woman experiencing intimate partner violence was assaulted by her partner on 31 January 2021 and died approximately 5 hours later. The assault caused significant blood loss; however, the medical cause of de…

forensic medicinepaediatricssystemcommunicationmethamphetamine
NT2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
VIChospital2025-09-25

Finding into death of Dio Miranda Katiana Kemp

3y · Female·Streptococcus pyogenes septicaemia

A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…

emergency medicinepaediatricsdiagnosticcommunication
VIChospital2025-09-03

Finding into death of Olivia Alexandra Evans

15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa

Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…

psychiatrypaediatricsdiagnosticsystemparacetamol
VIChome2025-08-28

Finding into death of MJU & KJH

39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back

MJU (39) and her daughter KJH (6) were killed by MJU's husband CTH in a family violence homicide on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinati…

psychiatryemergency medicinediagnosticcommunicationmethamphetamine
NSWhome2025-08-28

Inquest into the death of KBS

1y · Male·Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrh…

A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib fractures, extensive bruising, and patterned…

paediatricsforensic medicinecommunicationsystemcannabis
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

A 7-year-old boy died in a head-on motor vehicle collision after his father deliberately drove their newly purchased car into an oncoming truck. The father had recently experienced severe stress following his partner's d…

paediatricspsychiatrycommunicationsystemmirtazapine
VIChome2025-08-20

Finding into death of GFD

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…

paediatricsforensic medicinesystemcommunication
NT2025-08-12

Inquest into the death of Didbala Anzac

17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…

Didbala, a 17-year-old Aboriginal girl with complex mental health conditions including psychosis, bipolar disorder and suspected FASD, died by hanging at a CASPA residential care house in Katherine on 3 October 2022. She…

psychiatrypsychologycommunicationsystemcannabis
NSWhome2025-08-08

Inquest into the death of Jacob

0y · Male·Non-accidental infliction of significant force to the head/face and gum region, …

Jacob, a premature infant born at 29 weeks, was discharged from neonatal care at 11 weeks old and presented to hospital three days later with a subarachnoid haemorrhage and periorbital bruising. Despite being assessed as…

paediatricsforensic medicinediagnosticsystemmethamphetamine
VIChome2025-07-28

Finding into death of Aluel Ajak

9y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian)

Aluel Ajak, a 9-year-old girl with autism spectrum disorder, severe developmental delay, and moderate intellectual disability, died from injuries sustained when struck by a motor vehicle after absconding from her home. S…

paediatricsdisability medicinesystemdelayclonidine
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