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VIChospitalNew2026-07-01

Finding into death of Baby H

0y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant

Baby H died on 24 March 2019, one day after birth, from traumatic head injuries sustained during an instrumental vaginal delivery using Neville Barnes forceps on a baby in occipito-posterior position. Critical clinical l…

obstetricsgeneral practicecommunicationprocedural
QLDhospital2026-05-07

Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…

Lucy Margaret Campbell died eight days after birth from severe hypoxic ischemic encephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneo…

obstetricsmidwiferydiagnosticcommunicationoxytocin
WA2026-01-08

Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…

cardiologyemergency medicinediagnosticsystem
VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…

Jordan was born at 25 weeks 4 days gestation in an emergency department following precipitant breech labour with a circumvallate placenta. He received appropriate initial resuscitation but was administered 10 times the p…

neonatologyobstetricsmedicationdiagnosticmorphine
VIChospital2024-08-06

Finding into death of Noah Andrew Souvatzis

1y · Male·acute meningitis from Streptococcus pneumoniae, associated with diffuse brain sw…

Noah Souvatzis, a 19-month-old boy, died from Streptococcus pneumoniae meningitis on 31 December 2021 after presenting to Northeast Health Wangaratta ED on 29 December. Critical failures in his first ED presentation incl…

emergency medicinepaediatricsdiagnosticproceduralondansetron
NSWhospital2024-05-10

Inquest into the death of Finlay Browne

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…

emergency medicinesurgerydiagnosticcommunication
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…

paediatricsemergency medicinecommunicationsystemadrenaline
NSWhospital2022-05-30

Inquest into the death of Alex BRAES

18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection

Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to seps…

emergency medicineinfectious diseasessystemdelayceftriaxone
VIChospital2022-04-28

Finding into death of Hunter Patrick Boyle

2y · Male·Consistent with drowning

Hunter Patrick Boyle, a 2-year-old boy, drowned in a farm dam while under the care of his grandfather. Hunter and his grandfather visited a neighbouring property to feed a horse; within 30 seconds to 1 minute of losing s…

emergency medicinepaediatricsmorphine
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…

plastic and reconstructive surgeryintensive carecommunicationsystem
VIChome2021-02-24

Finding into death of Jordan Malcolm Colin White

1y · Male·Hypoxic ischaemic encephalopathy due to neck compression from faulty portacot

Jordan White, a 14-month-old boy, died from hypoxic ischaemic encephalopathy caused by neck compression when trapped in a faulty portacot. The portable cot had a defective bottom rail that would not lock, leaving it in a…

intensive careneurologysystem
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagno…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol
VIChospital2020-07-02

Finding into death of Cai Wheeler-Trow

0y · Male·Head injury in the setting of labour

Baby Cai Wheeler-Trow was born at 36 weeks and 2 days following a failed instrumental delivery and emergency caesarean section. He developed a skull fracture and subgaleal haemorrhage, presenting with clinical deteriorat…

obstetricspaediatricsdiagnosticcommunication
VIChospital2020-05-21

Finding into death of Baby S

Female·Sepsis in the setting of a lotus birth

A premature female neonate born at 36+5 weeks via emergency caesarean section developed sepsis and died at 2 days of age. She had been delivered with lotus birth (cord left attached to placenta) and vaginal seeding (mate…

obstetricspaediatricscommunicationsystembenzylpenicillin
QLDrural hospital2020-05-08

FD - Non-inquest findings

68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…

A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…

gastroenterologyemergency medicinediagnosticcommunicationaugmentin duo
NSWcommunity2020-03-25

Inquest into the death of Tory GANDERTON

3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause

Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…

paediatricsneurologycommunicationsystemadrenaline
NSWcommunity2020-01-24

Into the death of Thomas Redman

18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…

Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…

emergency medicinetrauma surgerycommunicationsystemoxygen
NT2019-08-09

Inquest into the death of Robin Riley, Thomas Turpin, Fabian Andrews, Cassandra Martin

Blunt force trauma from motor vehicle accident (four deceased: head injuries in …

Four people died in a single vehicle rollover on Kakadu Highway, NT. The driver (Robin Riley, 46) and three unrestrained passengers (Thomas Turpin, 39; Cassandra Martin, 32; Fabian Andrews, 45) were killed when their veh…

emergency medicineretrieval medicinesystemdelayalcohol
VIChospital2018-10-26

Finding into death of Baby B

1y · Male·Hypoxic-ischaemic encephalopathy and multisystem failure in the setting of extre…

Baby B was born by emergency breech extraction in an ambulance after obstructed labour, sustaining severe hypoxic-ischaemic injury. The death was multifactorial. The mother had limited antenatal care despite known metham…

obstetricsneonatologydiagnosticsystemmethamphetamine
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Pur…

emergency medicinevascular surgerydiagnosticcommunicationgentamicin

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