294 results
Female·Combination of liver failure, blood loss and shock following needle biopsy
Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…
16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …
A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…
3y · Male·asphyxia secondary to epilepsy
Jayden Lynch, aged 3, died on 15 December 2008 while attending family day care in Yamba, NSW. He had epilepsy managed by a paediatrician with medications (Tegratol, Trileptac) and emergency rectal diazepam. On the day of…
4y · Female·consequences of incarcerated congenital left diaphragmatic hernia
Madison Ormerod, aged 4 years, died from incarcerated congenital left diaphragmatic hernia. Over 3 months before death, she presented with persistent vomiting and abdominal pain to her GP and paediatrician. The paediatri…
Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…
Helani Sirianni, born 8 February 2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extract…
8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…
Eight-year-old Isaraelu Pele died of bacterial meningitis missed by multiple clinicians despite three hospital presentations and two GP visits between 14–17 December 2007. Critical failures included: inadequate different…
13y · Female·cardiac arrest resulting from dehydration
A 13-month-old girl with short bowel syndrome died from cardiac arrest due to severe dehydration. She had been deteriorating with diarrhoea and vomiting on 18 February 2009, prompting nursing staff to escalate concerns t…
15y · Female·Ligature compression of the neck (hanging)
A 15-year-old Aboriginal girl died by suicide by hanging on 29 November 2007. She had a transient lifestyle with unstable housing, moved frequently between relatives, was not regularly attending school, and engaged in su…
0y · Male·failure to thrive due to insufficient caloric intake
Kalib died from failure to thrive due to insufficient caloric intake at 7 weeks old. He was born to a mother with a documented history of severe neglect and physical abuse of multiple children over 5 years, during which …
12y · Female·acute septicaemia resulting from osteomyelitis of the left femur
A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…
14y · Female·hanging
Sharkia Handy, a 14-year-old girl in out-of-home care, died by hanging in December 2007. She had significant unaddressed mental health concerns including suicidal ideation, self-harm, and grief following peer suicides. T…
14y · Male·gunshot wound to the head
Andrew Scott Anderson was a 14-year-old boy placed in Department of Child Safety care following his father's physical assault. He had a longstanding history of behavioral difficulties, ADHD, depression, and substance use…
1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)
Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory rate…
15y · Female·Hanging (self-inflicted)
A 15-year-old Aboriginal girl in a remote Central Australian community died by suicide following a year marked by petrol sniffing, sexual abuse concerns, and reported suicide attempts. She suffered multiple sexually tran…
0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery
Declan Brian McConville was born with shoulder dystocia (impacted shoulders) after vacuum-assisted delivery at Royal Darwin Hospital on 31 August 2007. He was stuck in the birth canal for approximately 15 minutes before …
10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media
Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seei…
7y · Female·streptococcus pneumoniae sepsis complicating retropharyngeal abscess
A 7-week-old infant died from streptococcus pneumoniae sepsis complicating retropharyngeal abscess. Three days before death, a report was made to child protection services alleging the father had shaken the infants. A ge…
0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…
Georgia Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contribut…
0y · Male·Respiratory insufficiency; interstitial fibrosis and low-grade pneumonitis of pr…
Zakaria Tartoussi died at age 43 days from respiratory insufficiency due to interstitial fibrosis and low-grade pneumonitis of probable viral aetiology. He presented for medical attention five times in six weeks with sym…
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