76 results
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…
8y · Male·prematurity-associated lung and bowel disease
Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…
2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection
A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…
0y · Male·Severe acute dehydration and acute malnutrition
An eight-month-old boy died from severe acute dehydration and malnutrition after receiving no or minimal fluid or food intake during a three-day drug binge by his mother and her partner. Child Safety was involved with th…
11y · Male·complications of brown snake envenomation
This ruling addresses scope determination for an inquest into the death of Tristian James Frahm, an 11-year-old Aboriginal boy who died from brown snake envenomation while at his father's rural property in November 2021.…
5y · Male·Complications of burns
A 5-year-old boy died from complications of severe burns sustained during a fuel ignition incident at his father's rural property. While refuelling a small motorcycle, the father failed to shut off the engine and did not…
2y · Female·Complications of bacterial chest infection (Staphylococcus aureus)
A 2-year-old Aboriginal and Torres Strait Islander girl died from complications of bacterial chest infection (Staphylococcus aureus) with concurrent Human metapneumovirus infection, presenting as left empyema and bilater…
13y · Unknown·Drowning
A 13-year-old child in state care died by drowning at Cedar Creek Falls on 8 April 2021. The coroner found that the youth worker Mr La's decision-making was reasonable, including not using physical restraint when the boy…
32y · Female·Unknown
Tina Louise Greer, 32, disappeared on 18 January 2012 and is presumed deceased, killed by her partner Leslie Sharman who was involved in her coercive and controlling relationship, including domestic violence. The coroner…
8y · Male·ischaemic bowel due to strangulated small bowel obstruction secondary to congeni…
An eight-year-old boy with autism spectrum disorder (level 1) died from ischaemic bowel due to strangulated small bowel obstruction from a rare congenital band adhesion. He presented to a regional hospital with abdominal…
2y · Male·Crush chest injuries
A two-year-old boy died from crush chest injuries after a heavy homemade hallway table (approximately 70kg, made from a railway sleeper) toppled onto him while he was playing at home. He was found unresponsive by his par…
0y · Male·Acute traumatic head injury (non-accidental)
A 7-month-old child died from acute traumatic head injury sustained from non-accidental blunt force. Clinical lessons include: medical staff should strongly reinforce urgent referrals (the child had a critical GP referra…
14y · Male·Hanging
A 14-year-old boy died by hanging after extensive exposure to domestic and family violence and child abuse, primarily from his father. Child Safety Services involvement began in infancy but failed to apply a trauma-infor…
5y · Male·Hypoxic ischaemic encephalopathy due to near-drowning
A 5-year-old boy who could not swim drowned in a public aquatic centre after crossing from a shallow ramp area into a 1.2-metre deep main pool, unobserved by his parents. He was underwater for 90 seconds before being ret…
12y · Female·Undetermined (asphyxiation or choking)
Tiahleigh Palmer, age 12, was murdered on 29 October 2015 by her foster carer Richard Thorburn, who asphyxiated or choked her. The coroner identified critical systemic failures including: inadequate permanency planning b…
0y · Unknown·Category II Sudden Infant Death Syndrome (co-sleeping)
Baby J, a healthy 23-week-old infant, died from Category II Sudden Infant Death Syndrome (SIDS) associated with co-sleeping. He was found unresponsive while sleeping chest-to-chest with his father on makeshift bedding wi…
0y · Male·Sudden infant death syndrome category II (SIDS) - accidental asphyxiation due to…
An 8-week-old infant died from SIDS category II, likely due to accidental asphyxiation when the mother fell asleep and slumped forward over him. The infant was born to a mother with a 12-year history of heroin addiction …
0y · Female·Sudden infant death syndrome or asphyxiation due to co-sleeping or overlaying
An 11-week-old infant died while co-sleeping with her mother in a bed shared with siblings. The mother had smoked cannabis before sleep and was found overlaying the infant at 3:30am; the baby was discovered head-down bes…
4y · Male·Intra-abdominal injuries from blunt force trauma (ruptured duodenum and lacerate…
Tyrell Cobb, a 4-year-old boy, died from intra-abdominal injuries caused by blunt force trauma inflicted on two separate occasions between 22-24 May 2009. Postmortem revealed a ruptured duodenum and lacerated mesentery c…
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…
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