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TAShome2025-08-28

Coroner's Finding: de-identified XY

10y · Male·catastrophic brain injury with multiple brain bleeds

A 10-month-old child died from catastrophic brain injury with multiple brain bleeds inflicted by their mother's boyfriend during an episode of care at home. The perpetrator violently shook the infant, thrust his finger i…

paediatricsneurosurgery
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

Two premature infants died from unsafe sleeping environments while in the care of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay i…

paediatricspsychiatrydiagnosticcommunicationmethadone
TAShome2024-08-29

Coroner's Finding: De-identified PT

14y · Male·Brain infarction caused by hypoxia following self-inflicted hanging by rope liga…

PT was a 14-year-old boy with a history of anorexia nervosa and bulimia who died by hanging in April 2022. He had been discharged from eating disorder treatment in November 2021 after maintaining appropriate weight. In t…

psychiatrypaediatricssystem
TAShome2023-11-14

Coroner's Finding: de-identified OV

1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…

An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parent…

paediatricsemergency medicineadrenaline
TAShome2023-10-19

Coroner's Finding: de-identified FG

0y · Male·suffocation due to overlay by a sleeping adult

A 59-day-old premature infant died from suffocation due to overlay by a sleeping parent. The infant was placed on a mattress next to the parent's cot after refusing to settle in his own cot. Despite the parent's attempt …

paediatricsneonatologysystem
TAShospital2023-04-03

Coroner's Finding: RS - de-identified

1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephre…

A 19-month-old girl with history of Wilms tumour presented to Launceston General Hospital with vomiting, pain and lethargy. A Children's Early Warning Tool score of 6 triggered mandatory protocols including senior doctor…

emergency medicinepaediatricsdiagnosticsystem
TAShome2022-09-20

Coroner's Finding: Infant F - De-identified

2y · Male·unexplained sudden death

A previously healthy 2-month-old infant died unexpectedly during sleep. Post-mortem examination revealed aspiration of gastric contents with early aspiration pneumonia, rhinovirus infection, and trace amounts of fluoxeti…

paediatricsmidwiferyfluoxetine
TAShome2022-06-30

Coroner's Finding: MX De-identified

5y · Unknown·Undetermined Sudden Infant Death (USID)

A 5-month-old infant died suddenly while co-sleeping with his mother on an adult bed with adult bedding. Post-mortem examination revealed undetermined sudden infant death (USID) with reactive splenic changes consistent w…

pathologypaediatrics
TAShome2022-02-23

Coroner's Finding: BR - deidentified

0y · Female·Undetermined - coroner unable to determine exact cause; unsafe sleeping environm…

A 5-month-old infant died suddenly in a co-sleeping environment with adults and a toddler in a queen-sized bed with adult bedding. Autopsy revealed no definitive cause but identified significant risk factors: unsafe slee…

paediatricsneonatologysystem
TAS2021-09-17

Coroner's Finding: Infant Deaths

varied: sudden unexpected death in infancy (unsafe sleeping environment); drowni…

Coroner's joint inquest into deaths of seven children (six infants and one child aged 16 years) between 2014 and 2018 in Tasmania. All families had history of Child Safety Services (CSS) involvement. Coroner found no dir…

paediatricspsychiatrydiagnosticcommunicationalcohol
TAShospital2021-08-26

Coroner's Finding: PY

0y · Unknown·sepsis leading to multiple organ failure syndrome

A 48-day-old neonate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw …

paediatricsemergency medicinediagnosticdelayparacetamol
TAShospital2021-07-02

Coroner's Finding: HB

8y · Male·acute exacerbation of chronic asthma

An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…

paediatricsemergency medicinediagnosticcommunicationfluticasone/salmeterol
TAShospital2021-03-19

Coroner's Finding: Master T

3y · Male·Hypoxic brain injury secondary to cardiorespiratory arrest, possibly secondary t…

Master T, aged 3 years, died from hypoxic brain injury secondary to cardiorespiratory arrest, likely due to aspiration pneumonitis. He had severe congenital abnormalities including holoprosencephaly with VP shunt, anal a…

paediatricsintensive careparacetamol
TAShome2020-05-19

Coroner's Finding: Baby I

1y · Female·Suffocation due to co-sleeping (bed sharing)

A one-month-old infant died from suffocation while co-sleeping with her mother on a couch. The mother fell asleep while breastfeeding, with the baby positioned between her and the couch back. The death was completely pre…

paediatricsforensic medicine
TAShome2020-05-18

Coroner's Finding: Baby E

5y · Female·suffocation

A five-month-old girl died from suffocation while co-sleeping in an adult bed with both parents and an older sibling. The infant was anatomically normal and in good health at the time of death. Co-sleeping posed an inher…

paediatricsforensic medicine
TAShome2020-03-09

Coroner's Finding: MH

0y · Female·Suffocation due to unsafe sleeping environment with overlying and/or bedding ent…

A 7-week-old baby died following unsafe sleep practices. Born prematurely at 37 weeks with reflux and bronchopneumonia, the infant was placed to sleep on an adult mattress with two adults and another child, rather than i…

paediatricsforensic medicinesystem
TASmental health2019-08-02

Coroner's Finding: Mead, Liam - Ruling on Evidence

Male·not_stated

Liam Mead, a teenager, died on 7 March 2017, two days after discharge from an inpatient psychiatric facility in Victoria. He had experienced functional deterioration in late 2016 related to psychosocial stressors and was…

psychiatrypaediatricssystemdelay
TAShome2019-06-26

Coroner's Finding: Lukendlay, Charlotte (OM) Findings

0y · Female·global hypoxic brain injury caused by prolonged cessation of breathing arising f…

An 11-week-old healthy infant died from global hypoxic brain injury following cardiac arrest at home. Multiple rib fractures and a clavicle fracture in various stages of healing indicated repeated non-accidental trauma i…

paediatricsintensive caresystem
TAShome2018-12-17

Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

0y · Female·Sudden infant death whilst bed-sharing with risk factors including unsafe sleepi…

A 55-day-old infant died in an unsafe bed-sharing environment with her sedated mother while her father, intoxicated by intravenous morphine and methamphetamine, remained nearby. The autopsy revealed no obvious cause, but…

paediatricsforensic medicinesystemdelaymorphine
TAShome2018-11-09

Coroner's Finding: Van Galen, Esther Grace

0y · Female·Sudden infant death while bed-sharing

A 7-week-old premature infant died of sudden infant death while bed-sharing with her mother on a couch. The infant was born at 33 weeks gestation weighing 1.7kg and discharged home after achieving adequate growth. She wa…

paediatricsneonatologysystem

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