545 results
0y · Male·dehydration complicating diarrhoea (aetiology unknown)
A 10-week-old infant in out-of-home care in a remote Western Australian community developed acute diarrhoea and fever one day after routine immunisation. Despite appropriate initial care by foster parents and timely hosp…
5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …
A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…
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…
0y · Female·Sudden Infant Death Syndrome (SIDS Category II)
A 3-month-old female infant died from Sudden Infant Death Syndrome (SIDS Category II) after co-sleeping with her parents. The death occurred in the context of unsafe sleeping practices despite prior intervention by Child…
0y · Male·meconium aspiration syndrome complicated by persistent pulmonary hypertension
Baby C was born at 41 weeks and 2 days covered in thick meconium with respiratory distress. Key clinical failures included: (1) failure to respond to mother's request for induction at term+6 days; (2) failure to investig…
17y · Female·ligature compression of the neck (hanging)
A 17-year-old girl in state care died by suicide on 16 April 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver…
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…
3y · Male·Hypoxic ischaemic encephalopathy complicating drowning
A 3-year-old boy drowned in a home swimming pool after the pool gate failed to latch properly due to wear and lack of maintenance. The gate did not comply with Australian Standards requiring self-closing and self-latchin…
0y · Female·Disseminated Herpes Simplex Virus (HSV 1)
An 11-day-old neonate died from disseminated HSV-1 infection acquired perinatally. She presented with sepsis-like symptoms including lethargy, poor feeding, fever and respiratory signs. Clinical management was appropriat…
1y · Male·Abdominal injuries (perforation of small bowel and mesentery with peritonitis pr…
Mason Lee, aged 22 months, died on 11 June 2016 from abdominal injuries inflicted by his mother's partner, William O'Sullivan, combined with severe neglect. Mason was admitted to hospital in February 2016 with severe per…
2y · Female·drowning
A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurred: the chil…
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…
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…
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…
Female·Drowning
Two young sisters, aged 4 and 3 years, drowned in a residential swimming pool while unsupervised. Both parents were present in the home but inattentive—the mother was asleep in the bedroom while the father was using his …
0y · Male·Unascertained in the setting of detected methylamphetamine
A nearly 4-month-old boy was found unresponsive in his bassinet and could not be revived. Autopsy revealed facial bruising and injuries, and toxicological analysis detected methylamphetamine in his blood and hair. The ca…
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…
11y · Male·Sepsis
An 11-week-old premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a three-hour delay. Key failures inclu…
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…
5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …
A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…
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